Healthcare Provider Details

I. General information

NPI: 1528830163
Provider Name (Legal Business Name): INTEGRIS HEALTH PONCA CITY HOSPITAL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2023
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1908 N 14TH ST STE 202, 203 & 207
PONCA CITY OK
74601-2039
US

IV. Provider business mailing address

3001 QUAIL SPRINGS PKWY FL 3
OKLAHOMA CITY OK
73134-2640
US

V. Phone/Fax

Practice location:
  • Phone: 580-718-4501
  • Fax:
Mailing address:
  • Phone: 405-252-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DONNA WALLACE
Title or Position: ASSISTANT TREASURER
Credential:
Phone: 636-359-4890