Basic Information
| Provider Information | |||||||||
| NPI: | 1437476561 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SSM HEALTH CARE OF OKLAHOMA, INC. | ||||||||
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| OtherOrganizationName: | SSM HEALTH ST. ANTHONY HOSPITAL - OKLAHOMA CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 N LEE AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021036 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052727000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 N LEE AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052727000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2010 | ||||||||
| LastUpdateDate: | 08/30/2018 | ||||||||
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| AuthorizedOfficialLastName: | MANUEL | ||||||||
| AuthorizedOfficialFirstName: | SHASTA | ||||||||
| AuthorizedOfficialMiddleName: | RENE | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL VP - FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4052727279 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE OF OKLAHOMA, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 100699540K | 05 | OK | MEDICAID |