Basic Information
| Provider Information | |||||||||
| NPI: | 1760483846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRIS RURAL HEALTH INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HENNESSEY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 960183 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960183 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805481367 | ||||||||
| FaxNumber: | 5805481583 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 N CHEROKEE ST | ||||||||
| Address2: | |||||||||
| City: | HENNESSEY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737421106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058537171 | ||||||||
| FaxNumber: | 4058536662 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 01/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 5805481367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200034700A | 05 | OK | MEDICAID | 200069200Y | 01 | OK | OK MEDICAID OSUSC | OTHER | 200069200M | 01 | OK | OK MEDICAID OSUFFS | OTHER |