Provider Demographics
NPI:1154681450
Name:SSM HEALTHCARE OF OK, INC
Entity Type:Organization
Organization Name:SSM HEALTHCARE OF OK, INC
Other - Org Name:ST ANTHONY PHYSICIANS - MIDTOWN RENAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-272-7452
Mailing Address - Street 1:PO BOX 269064
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9064
Mailing Address - Country:US
Mailing Address - Phone:405-272-7452
Mailing Address - Fax:405-272-7937
Practice Address - Street 1:810 NW 10TH ST
Practice Address - Street 2:SUITE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-7215
Practice Address - Country:US
Practice Address - Phone:405-272-8367
Practice Address - Fax:405-272-8373
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTHCARE OF OK, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK22892207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty