MEDICARE: SSM HEALTHCARE OF OKLAHOMA, INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0129X	Vascular Surgery Physician

General Provider Information

NPI Number	:	1033408497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SSM HEALTHCARE OF OKLAHOMA, INC

Provider Business Mailing Address
First Line	:	PO BOX 269064
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126-9064
Country	:	US
Telephone Number	:	405-272-7452
Fax Number	:	405-272-7937

Provider Business Practice Location Address
First Line	:	608 NW 9TH ST
Second Line	:	SUITE 5204
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73102-1068
Country	:	US
Telephone Number	:	405-232-2178
Fax Number	:	405-232-6617

Authorized Official
Title or Position	:	CREDENTIALING SPECIALIST
Name	:	CRYSTAL L PENA
Credential	:
Telephone Number	:	405-272-7452

Provider Enumeration Date	:	04/06/2011
Last Update Date	:	07/07/2011

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