Provider Demographics
NPI:1730180894
Name:INTEGRIS BASS BAPTIST HEALTH CENTER
Entity type:Organization
Organization Name:INTEGRIS BASS BAPTIST HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:636-359-4890
Mailing Address - Street 1:PO BOX 200731
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-0731
Mailing Address - Country:US
Mailing Address - Phone:405-252-8400
Mailing Address - Fax:
Practice Address - Street 1:158 E SUNSET DR
Practice Address - Street 2:STE B
Practice Address - City:MEDFORD
Practice Address - State:OK
Practice Address - Zip Code:73759-2427
Practice Address - Country:US
Practice Address - Phone:580-395-2319
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-10
Last Update Date:2025-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100755790AMedicaid
OK100699500NMedicaid
OK100755790BMedicaid
OK100755790AMedicaid
OKCQ2518Medicare PIN
OK600522059Medicare PIN
OK373873Medicare Oscar/Certification