Provider Demographics
NPI:1083827646
Name:MCBRIDE CLINIC, INC.
Entity Type:Organization
Organization Name:MCBRIDE CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:GALLIART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-486-2100
Mailing Address - Street 1:400 N BRYANT AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-3208
Mailing Address - Country:US
Mailing Address - Phone:405-230-9200
Mailing Address - Fax:405-330-5591
Practice Address - Street 1:400 N BRYANT AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-3208
Practice Address - Country:US
Practice Address - Phone:405-230-9200
Practice Address - Fax:405-330-5591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic SurgeryGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100758280BMedicaid
OK=========001OtherBCBS OF OKLAHOMA
OK=========001OtherBCBS OF OKLAHOMA