Provider Demographics
NPI:1639196355
Name:MERCY HEALTH CANADIAN COUNTY AMBULATORY SURGICAL CENTER LLC
Entity Type:Organization
Organization Name:MERCY HEALTH CANADIAN COUNTY AMBULATORY SURGICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:SMALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-752-3756
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE #141; ATTN: BECKY
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1785
Mailing Address - Country:US
Mailing Address - Phone:405-936-5811
Mailing Address - Fax:405-936-5810
Practice Address - Street 1:520 S MUSTANG RD
Practice Address - Street 2:SUITE S
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099-6737
Practice Address - Country:US
Practice Address - Phone:405-936-5900
Practice Address - Fax:405-577-2032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0060261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK000371045-001OtherBC/BS #