Healthcare Provider Details

I. General information

NPI: 1124300512
Provider Name (Legal Business Name): SSM HEALTHCARE OF OK, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/13/2011
Last Update Date: 09/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N LEE AVE 4TH FLOOR
OKLAHOMA CITY OK
73102-1036
US

IV. Provider business mailing address

3330 NW 56TH ST SUITE 206
OKLAHOMA CITY OK
73112-4479
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-7699
  • Fax: 405-272-6662
Mailing address:
  • Phone: 405-945-4760
  • Fax: 405-562-9242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number
License Number State

VIII. Authorized Official

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