Basic Information
| Provider Information | |||||||||
| NPI: | 1710113121 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS RURAL HEALTH, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | FAMILY PHYSICIANS OF THE PLAINS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960379 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960379 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805481367 | ||||||||
| FaxNumber: | 5805481583 | ||||||||
| Practice Location | |||||||||
| Address1: | 915 E GARRIOTT RD | ||||||||
| Address2: | SUITE G | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737016156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802425100 | ||||||||
| FaxNumber: | 5802422700 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2009 | ||||||||
| LastUpdateDate: | 08/24/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP INTEGRIS RURAL PHY PRACT MGMT | ||||||||
| AuthorizedOfficialTelephone: | 5805481367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 19950 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200219500B | 05 | OK | MEDICAID | 200119080R | 05 | OK | MEDICAID |