Basic Information
| Provider Information | |||||||||
| NPI: | 1710970033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BAPTIST HEALTHCARE OF OKLAHOMA, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | PAIN MANAGEMENT CENTER OF NORTHWEST OKLAHOMA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5587 | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737025587 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805481367 | ||||||||
| FaxNumber: | 5805481537 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 S 3RD ST | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737015737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802377246 | ||||||||
| FaxNumber: | 5802494152 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2005 | ||||||||
| LastUpdateDate: | 01/27/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MEYERS | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4059493774 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
No ID Information.