Basic Information
| Provider Information | |||||||||
| NPI: | 1629056601 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS RURAL HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | INTEGRIS BASS PSYCHIATRIC SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5038 | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737025038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805481367 | ||||||||
| FaxNumber: | 5805481537 | ||||||||
| Practice Location | |||||||||
| Address1: | 2216 S VAN BUREN ST | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737038217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802342220 | ||||||||
| FaxNumber: | 5802338922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2006 | ||||||||
| LastUpdateDate: | 01/23/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5805481367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 200069200Z | 01 | OK | MEDICAID OSUFFS | OTHER | 200065440A | 05 | OK | MEDICAID |