Healthcare Provider Details

I. General information

NPI: 1659413649
Provider Name (Legal Business Name): MCBRIDE CLINIC ORTHOPEDIC HOSPITAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/13/2007
Last Update Date: 04/12/2024
Certification Date: 04/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9600 BROADWAY EXT
OKLAHOMA CITY OK
73114-7408
US

IV. Provider business mailing address

9600 BROADWAY EXT
OKLAHOMA CITY OK
73114-7408
US

V. Phone/Fax

Practice location:
  • Phone: 405-486-2100
  • Fax: 405-486-2504
Mailing address:
  • Phone: 405-486-2100
  • Fax: 405-486-2504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XS0106X
TaxonomyOrthopaedic Hand Surgery Physician
License Number2369
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number2369
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License Number2369
License Number StateOK
# 4
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number2369
License Number StateOK
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number2369
License Number StateOK
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2369
License Number StateOK
# 7
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2369
License Number StateOK
# 8
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number2369
License Number StateOK
# 9
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number2369
License Number StateOK
# 10
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2369
License Number StateOK

VIII. Authorized Official

Name: MARK GALLIART
Title or Position: CEO
Credential:
Phone: 405-486-2100