=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053327486
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BASS MEMORIAL BAPTIST HOSPITAL DBA INTEGRIS BASS BAPTIST HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2006
-----------------------------------------------------
Last Update Date | 12/19/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 915 E GARRIOTT RD SUITE D
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-6156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-234-8998
-----------------------------------------------------
Fax | 580-234-8465
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5038
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73702-5038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-548-1367
-----------------------------------------------------
Fax | 580-548-1583
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT AND CEO
-----------------------------------------------------
Name | CARL B. LAWRENCE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-951-2616
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------