Basic Information
| Provider Information | |||||||||
| NPI: | 1437256070 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MERCY HOSPITAL OKLAHOMA CITY, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MERCY HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4300 W MEMORIAL RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057523724 | ||||||||
| FaxNumber: | 4057523811 | ||||||||
| Practice Location | |||||||||
| Address1: | 4401 W MEMORIAL RD STE 143 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054868600 | ||||||||
| FaxNumber: | 4057523598 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 09/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAHNE | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4059365649 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MERCY HOSPITAL OKLAHOMA CITY, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 7207 | OK | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 000377048-001 | 01 | OK | BC/BS # - HOME HEALTH | OTHER | 100699390B | 05 | OK | MEDICAID |