Basic Information
| Provider Information | |||||||||
| NPI: | 1962403030 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTEGRIS RURAL HEALTH INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | INTEGRIS CANADIAN VALLEY FAMILY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 960033 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805481367 | ||||||||
| FaxNumber: | 5805481583 | ||||||||
| Practice Location | |||||||||
| Address1: | 1468 N MUSTANG RD | ||||||||
| Address2: | |||||||||
| City: | MUSTANG | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730640000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053761800 | ||||||||
| FaxNumber: | 4053761856 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2005 | ||||||||
| LastUpdateDate: | 01/02/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BROWN | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF PHYSICIAN PRACTICE MANAGEMENT | ||||||||
| AuthorizedOfficialTelephone: | 5805481367 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200014470C | 01 | OK | MEDICAID SC | OTHER | 200014470D | 05 | OK | MEDICAID | 200014470B | 05 | OK | MEDICAID |