Basic Information
| Provider Information | |||||||||
| NPI: | 1598903981 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA HEART HOSPITAL LLC | ||||||||
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| OtherOrganizationName: | OKLAHOMA HEART HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4050 W MEMORIAL RD | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731208382 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056083300 | ||||||||
| FaxNumber: | 4056081550 | ||||||||
| Practice Location | |||||||||
| Address1: | 8121 NATIONAL AVE | ||||||||
| Address2: | MWC | ||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731107530 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057361100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARVEY | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4056083300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RP1001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RC0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 200009170A | 05 | OK | MEDICAID |