Healthcare Provider Details

I. General information

NPI: 1093125072
Provider Name (Legal Business Name): SSM HEALTHCARE OF OKLAHOMA, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2014
Last Update Date: 04/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 NW 9TH ST SUITE 3206
OKLAHOMA CITY OK
73102-1068
US

IV. Provider business mailing address

608 NW 9TH ST SUITE 3206
OKLAHOMA CITY OK
73102-1068
US

V. Phone/Fax

Practice location:
  • Phone: 405-772-4338
  • Fax: 405-772-4339
Mailing address:
  • Phone: 405-772-4338
  • Fax: 405-772-4339

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

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