Basic Information
| Provider Information | |||||||||
| NPI: | 1558326421 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS BAPTIST REGIONAL HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | MIAMI FOOT AND ANKLE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 30 B ST SW | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185425551 | ||||||||
| FaxNumber: | 9187873864 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 B ST SW | ||||||||
| Address2: | |||||||||
| City: | MIAMI | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185425551 | ||||||||
| FaxNumber: | 9187873864 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2006 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HART | ||||||||
| AuthorizedOfficialFirstName: | JOEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9185426611 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.