Basic Information
| Provider Information | |||||||||
| NPI: | 1770626608 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRIS GROVE HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INTEGRIS GROVE EMS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5400 N INDEPENDENCE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125300 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1001 E 18TH STREET | ||||||||
| Address2: | |||||||||
| City: | GROVE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743445304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187862243 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 03/24/2017 | ||||||||
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| AuthorizedOfficialLastName: | LAWRENCE | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
| AuthorizedOfficialMiddleName: | BRUCE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT CEO | ||||||||
| AuthorizedOfficialTelephone: | 4059493177 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 341600000X | 2184 | OK | Y | Transportation Services | Ambulance |
ID Information
| ID | Type | State | Issuer | Description | 100699700D | 05 | OK | MEDICAID |