Healthcare Provider Details

I. General information

NPI: 1780953240
Provider Name (Legal Business Name): SSM HEALTHCARE OF OK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 12/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 S TULSA DRIVE
OKLAHOMA CITY OK
73170
US

IV. Provider business mailing address

PO BOX 269064
OKLAHOMA CITY OK
73126-9064
US

V. Phone/Fax

Practice location:
  • Phone: 405-815-5600
  • Fax: 405-272-7937
Mailing address:
  • Phone: 405-272-7452
  • Fax: 405-272-7937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL L PENA
Title or Position: INSURANCE CREDENTIALING SPECIALIST
Credential:
Phone: 405-272-7452