Provider Demographics
NPI:1457378184
Name:MERCY HEALTH NETWORK OF THE SOUTHERN REGION INC
Entity Type:Organization
Organization Name:MERCY HEALTH NETWORK OF THE SOUTHERN REGION INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:
Authorized Official - First Name:MALINDA
Authorized Official - Middle Name:S
Authorized Official - Last Name:BURDICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-220-6611
Mailing Address - Street 1:4401 W MEMORIAL RD
Mailing Address - Street 2:SUITE #141
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 1:1011 14TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1828
Practice Address - Country:US
Practice Address - Phone:580-220-6611
Practice Address - Fax:580-220-6185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200073380CMedicaid
OK200073380AMedicaid
OK600522047Medicare PIN