Basic Information
| Provider Information | |||||||||
| NPI: | 1487800512 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS RURAL HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | INTEGRIS NW MEDICAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960353 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805481367 | ||||||||
| FaxNumber: | 5805481583 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 S OAKWOOD RD STE B | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737034945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802341831 | ||||||||
| FaxNumber: | 5802341834 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/08/2008 | ||||||||
| LastUpdateDate: | 07/10/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEYERS | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5805481367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200219500A | 05 | OK | MEDICAID |