Provider Demographics
NPI:1114982527
Name:MERCY HEALTH SERVICES - SOUTHERN OKLAHOMA, LLC
Entity Type:Organization
Organization Name:MERCY HEALTH SERVICES - SOUTHERN OKLAHOMA, LLC
Other - Org Name:MERCY OCCUPATIONAL MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:BAKER
Authorized Official - Last Name:FORE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-226-7246
Mailing Address - Street 1:921 14TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1837
Mailing Address - Country:US
Mailing Address - Phone:580-223-5311
Mailing Address - Fax:580-223-8227
Practice Address - Street 1:921 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1837
Practice Address - Country:US
Practice Address - Phone:580-223-5311
Practice Address - Fax:580-223-8227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QX0100XAmbulatory Health Care FacilitiesClinic/CenterOccupational Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTAX ID FOR MERCY OCC MED