MEDICARE: INTEGRIS BASS BAPTIST HEALTH CENTER

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	261QR1300X	Rural Health Clinic/Center
2	207Q00000X	Family Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124029293
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRIS BASS BAPTIST HEALTH CENTER

Provider Business Mailing Address
First Line	:	PO BOX 200731
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75320-0731
Country	:	US
Telephone Number	:	405-252-8400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1084 NICKERSON ST
Second Line	:
City	:	WAYNOKA
State	:	OK
Zip	:	73860-1245
Country	:	US
Telephone Number	:	580-824-2281
Fax Number	:

Authorized Official
Title or Position	:	ASSISTANT TREASURER
Name	:	DONNA WALLACE
Credential	:
Telephone Number	:	636-359-4890

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	04/07/2025

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Directions to “INTEGRIS BASS BAPTIST HEALTH CENTER ” Practice Location

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