Provider Demographics
NPI:1770514044
Name:ST JOSEPHS CANCER CENTER OF NORTHERN
Entity type:Organization
Organization Name:ST JOSEPHS CANCER CENTER OF NORTHERN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER OPTION ONCOLOGY OKLAHOMA
Authorized Official - Prefix:MR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:R
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-400-0058
Mailing Address - Street 1:230 N MIDWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110
Mailing Address - Country:US
Mailing Address - Phone:580-767-1300
Mailing Address - Fax:580-767-1960
Practice Address - Street 1:609 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601
Practice Address - Country:US
Practice Address - Phone:580-767-1300
Practice Address - Fax:580-767-1960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200084810AMedicaid
OKMIDDE002Medicare ID - Type Unspecified
OK200084810AMedicaid