Basic Information
| Provider Information | |||||||||
| NPI: | 1942201397 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS BASS BAPTIST HEALTH CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INTEGRIS CALDWELL FAMILY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5400 N INDEPENDENCE AVE STE 200 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731125300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057135515 | ||||||||
| FaxNumber: | 4057135532 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 S OSAGE ST | ||||||||
| Address2: | |||||||||
| City: | CALDWELL | ||||||||
| State: | KS | ||||||||
| PostalCode: | 670221650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6208452516 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMMES | ||||||||
| AuthorizedOfficialFirstName: | CHRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VICE PRESIDENT & COO | ||||||||
| AuthorizedOfficialTelephone: | 4059493402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100755850B | 01 | OK | OK MEDICAID FFS | OTHER | 100100440 C | 01 | KS | KS MEDICAID RHC | OTHER | 100193490E | 01 | OK | OK MEDICAID SC | OTHER | 100699500P | 01 | OK | OK MEDICAID RHC | OTHER | 100699500P | 05 | OK | MEDICAID | 100100440 D | 01 | KS | KS MEDICAID FFS | OTHER | 460169 | 01 | KS | KS RHC CHILD MERCY | OTHER |