Provider Demographics
NPI:1124029293
Name:INTEGRIS BASS BAPTIST HEALTH CENTER
Entity Type:Organization
Organization Name:INTEGRIS BASS BAPTIST HEALTH CENTER
Other - Org Name:WAYNOKA FAMILY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP INTEGRIS REGIONAL PHYS PRACT MGM
Authorized Official - Prefix:
Authorized Official - First Name:GREG
Authorized Official - Middle Name:A
Authorized Official - Last Name:MEYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-977-1831
Mailing Address - Street 1:PO BOX 5038
Mailing Address - Street 2:
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73702-5038
Mailing Address - Country:US
Mailing Address - Phone:580-548-1367
Mailing Address - Fax:580-548-1537
Practice Address - Street 1:1084 NICKERSON ST
Practice Address - Street 2:
Practice Address - City:WAYNOKA
Practice Address - State:OK
Practice Address - Zip Code:73860-1245
Practice Address - Country:US
Practice Address - Phone:580-824-2291
Practice Address - Fax:580-824-0429
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699500KMedicaid
OK100755790CMedicaid
OK100755790CMedicaid
OKDA4816Medicare PIN
OK800522299Medicare PIN