Basic Information
| Provider Information | |||||||||
| NPI: | 1639196355 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MERCY HEALTH CANADIAN COUNTY AMBULATORY SURGICAL CENTER LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4401 W MEMORIAL RD | ||||||||
| Address2: | SUITE #141; ATTN: BECKY | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731341785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365811 | ||||||||
| FaxNumber: | 4059365810 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 S MUSTANG RD | ||||||||
| Address2: | SUITE S | ||||||||
| City: | YUKON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730996737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059365900 | ||||||||
| FaxNumber: | 4055772032 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| AuthorizedOfficialLastName: | SMALLEY | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | L. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4057523756 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | 0060 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
| ID | Type | State | Issuer | Description | 000371045-001 | 01 | OK | BC/BS # | OTHER |