Provider Demographics
NPI:1881659746
Name:BAPTIST HEALTHCARE OF OKLAHOMA
Entity Type:Organization
Organization Name:BAPTIST HEALTHCARE OF OKLAHOMA
Other - Org Name:INTEGRIS MAYES COUNTY MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:WEAVER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-825-1600
Mailing Address - Street 1:1301 NE 1ST ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-8850
Mailing Address - Country:US
Mailing Address - Phone:918-824-7777
Mailing Address - Fax:918-824-6414
Practice Address - Street 1:1301 NE 1ST ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-8850
Practice Address - Country:US
Practice Address - Phone:918-824-7777
Practice Address - Fax:918-824-6414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2011-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200039950AMedicaid
OK37D1030240OtherCLIA
OK500522114Medicare PIN
OK37D1030240OtherCLIA