1528060019 NPI number — INTEGRIS BASS BAPTIST HEALTH CENTER

Table of content: (NPI 1528060019)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528060019 NPI number — INTEGRIS BASS BAPTIST HEALTH CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRIS BASS BAPTIST HEALTH CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
GARBER FAMILY CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528060019
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5038
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ENID
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73702-5038
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-548-1367
Provider Business Mailing Address Fax Number:
580-548-1537

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
316 MAIN ST
Provider Second Line Business Practice Location Address:
PO BX 659
Provider Business Practice Location Address City Name:
GARBER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73738-0659
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-863-2204
Provider Business Practice Location Address Fax Number:
580-863-5309
Provider Enumeration Date:
08/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MEYERS
Authorized Official First Name:
GREG
Authorized Official Middle Name:
A
Authorized Official Title or Position:
SENIOR VICE PRESIDENT
Authorized Official Telephone Number:
580-977-1831

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100699500O , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100699500Z . This is a "OK MEDICAID SC" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100755850A . This is a "OK MEDICAID FFS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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