Provider Demographics
NPI:1760483846
Name:INTEGRIS RURAL HEALTH INC
Entity Type:Organization
Organization Name:INTEGRIS RURAL HEALTH INC
Other - Org Name:HENNESSEY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAWRENCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-548-1367
Mailing Address - Street 1:PO BOX 960183
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0183
Mailing Address - Country:US
Mailing Address - Phone:580-548-1367
Mailing Address - Fax:580-548-1583
Practice Address - Street 1:300 N CHEROKEE ST
Practice Address - Street 2:
Practice Address - City:HENNESSEY
Practice Address - State:OK
Practice Address - Zip Code:73742-1106
Practice Address - Country:US
Practice Address - Phone:405-853-7171
Practice Address - Fax:405-853-6662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200034700AMedicaid
OK200069200YOtherOK MEDICAID OSUSC
OK200069200MOtherOK MEDICAID OSUFFS
OK200069200MOtherOK MEDICAID OSUFFS
OK100522135Medicare PIN
OK200069200YOtherOK MEDICAID OSUSC