Basic Information
| Provider Information | |||||||||
| NPI: | 1649383035 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRIS BASS BAPTIST HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 N INDEPENDENCE AVE | ||||||||
| Address2: | #100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125310 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 S MONROE ST | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737017211 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802332300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 10/12/2011 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | BRUCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 4069496066 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 275N00000X | 2244 | OK | Y | Hospital Units | Medicare Defined Swing Bed Unit |
ID Information
| ID | Type | State | Issuer | Description | 100699500A | 05 | OK | MEDICAID |