Basic Information
Provider Information | |||||||||
NPI: | 1730288663 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SSM HEALTH CARE OF OKLAHOMA, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SSM HEALTH ST. ANTHONY HOSPITAL - OKLAHOMA CITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1000 N LEE AVE | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731021036 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052727000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1000 N LEE AVE | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 73102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052727000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/21/2006 | ||||||||
LastUpdateDate: | 02/04/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MANUEL | ||||||||
AuthorizedOfficialFirstName: | SHASTA | ||||||||
AuthorizedOfficialMiddleName: | RENE | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL VP - FINANCE | ||||||||
AuthorizedOfficialTelephone: | 4052727279 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SSM HEALTH CARE OF OKLAHOMA, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 02/04/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | 2304 | OK | Y |   | Hospital Units | Rehabilitation Unit |   |
No ID Information.