Healthcare Provider Details

I. General information

NPI: 1043576606
Provider Name (Legal Business Name): SSM HEALTHCARE OF OK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2012
Last Update Date: 04/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 NW 9TH ST SUITE 6200
OKLAHOMA CITY OK
73102-1068
US

IV. Provider business mailing address

PO BOX 269064
OKLAHOMA CITY OK
73126-9064
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-7677
  • Fax: 405-231-3783
Mailing address:
  • Phone: 405-272-7677
  • Fax: 405-231-3783

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State

VIII. Authorized Official

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