Healthcare Provider Details

I. General information

NPI: 1912244997
Provider Name (Legal Business Name): SSM HEALTHCARE OF OK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2013
Last Update Date: 01/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 NW 9TH ST SUITE 4106
OKLAHOMA CITY OK
73102-1068
US

IV. Provider business mailing address

608 NW 9TH ST SUITE 4106
OKLAHOMA CITY OK
73102-1068
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-5433
  • Fax: 405-272-5435
Mailing address:
  • Phone: 405-272-5433
  • Fax: 405-272-5435

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number27025
License Number StateOK

VIII. Authorized Official

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