NPIMap

Organization Active NPI

Integris Bass Baptist Health Center

Doing business as Integris Health Medical Group Waynoka

  • Family Medicine Physician
  • Waynoka, OK
National Provider Identifier
1124029293
Registry record updated Apr 7, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
INTEGRIS BASS BAPTIST HEALTH CENTER
Doing business as
Integris Health Medical Group Waynoka
Practice address
1084 Nickerson St
Waynoka, OK 73860-1245
Phone
(580) 824-2281
NPI assigned
Aug 10, 2005
Last updated
Apr 7, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 7, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Donna Wallace
Title
Assistant Treasurer
Phone
(636) 359-4890

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary
Rural Health Clinic/Center 261QR1300X

Addresses

Primary practice location

1084 Nickerson St
Waynoka, OK 73860-1245

Mailing address

PO Box 200731
Dallas, TX 75320-0731
Phone (405) 252-8400

Other names 1

  • INTEGRIS HEALTH MEDICAL GROUP WAYNOKA Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20030820000010 OK Part A Provider - Rural Health Clinic 0345151981 Practice locations: Waynoka, OK
O20031103000717 OK Part B Supplier - Clinic/Group Practice 0345151981 Receives reassigned benefits from 28 practitioners
17 other NPIs on this enrollment
Practice locations: Medford, OK; Hennessey, OK; Enid, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1124029293. Details of each certification follow.

Rural health clinic certification: CCN 373872

Legal name
INTEGRIS BASS BAPTIST HEALTH CENTER
Doing business as
INTEGRIS HEALTH MEDICAL GROUP WAYNOKA
Certification status
Terminated Voluntary: merger or closure, Dec 1, 2025
Provider type (POS)
Rural health clinic
Participating since
Jul 1, 2003
Last certification
Oct 12, 2023
Ownership / control type
2B
Organization structure
LLCNon-profit
Incorporated
Feb 14, 1994 in OK
Enrollment address
1084 Nickerson St
Waynoka, OK 73860-1245

Other NPIs with the same Medicare PAC ID 3

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 17

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

View all 17

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 24

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Elizabeth Partridge Individual Contracted Managing EmployeeDirector of Physician Operations Jul 1, 2024
Operational/Managerial ControlDirector of Physician Operations Jul 1, 2024
Christina Hopper Individual Corporate Officer Jul 1, 2024
Corporate Director Jul 1, 2024
Donna M Wallace Individual Corporate OfficerAssistant Treasurer Oct 27, 2023
Mark a McCulley Individual Corporate Director Jul 1, 2020
Christopher a Shearer Individual Corporate Director Apr 20, 2005
Brian D Atwood Individual Corporate Director Jan 1, 2002
Michael S Jackson Individual Corporate Officer May 1, 2019
Elizabeth R Kinzie Individual Contracted Managing EmployeeMD; Aug 31, 2017
Operational/Managerial ControlMedical Director Aug 31, 2017
Jason Turnbow Individual Corporate Director Jul 1, 2024
Michael L Weed Individual Corporate OfficerTreasurer Jan 1, 2023
Justin L Funk Individual Corporate Director Jul 1, 2024
Megan J Darrow Individual Corporate Director Jul 1, 2021
Integris Health Inc Organization, Oklahoma City, OK Corporation, Chain home office Operational/Managerial Control Jul 1, 1994
Brent Hubbard Individual Corporate Officer Jul 1, 2022
Corporate Director Jul 1, 2022
John R Bullis Individual Corporate Officer Jul 1, 2024
Corporate Director Jul 1, 2021
Baptist Healthcare of Oklahoma LLC Organization, Oklahoma City, OK LLC, Non-profit Operational/Managerial Control Jun 7, 1978
Brian Winter Individual Corporate Director Jul 1, 2024
Keaton Francis Individual Contracted Managing EmployeeChe Jan 9, 2023
Corporate OfficerChe Jan 9, 2023
Operational/Managerial ControlChe Jan 9, 2023
Integris Rural Health Inc Organization, Oklahoma City, OK Corporation, Non-profit Operational/Managerial Control Jul 1, 1994
Amber D Bellar Individual Contracted Managing EmployeeAd;Clinic Director Jul 1, 2024
Operational/Managerial ControlClinic Director Jul 1, 2024
Jonathan C Bartley Individual Corporate Officer Jul 1, 2024
Corporate Director Jul 1, 2020
Aaron Harmon Individual Corporate Director Jul 1, 2024
Casey Felix Individual Corporate Director Jul 1, 2018
Best Chen Individual Corporate Officer Jul 1, 2024
Corporate Director Jul 1, 2024

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Facilities with the same owner 31

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 31

Practitioners & affiliated clinicians

Practitioners 39

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 39

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1123632000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1743984000000",
    "number": "1124029293",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 200731",
            "city": "DALLAS",
            "state": "TX",
            "postal_code": "753200731",
            "telephone_number": "405-252-8400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1084 NICKERSON ST",
            "city": "WAYNOKA",
            "state": "OK",
            "postal_code": "738601245",
            "telephone_number": "580-824-2281"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRIS BASS BAPTIST HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-10",
        "last_updated": "2025-04-07",
        "certification_date": "2025-04-07",
        "status": "A",
        "authorized_official_last_name": "WALLACE",
        "authorized_official_first_name": "DONNA",
        "authorized_official_title_or_position": "ASSISTANT TREASURER",
        "authorized_official_telephone_number": "636-359-4890"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "INTEGRIS HEALTH MEDICAL GROUP WAYNOKA",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Waynoka, OK

Sources for this page

Verify at the official NPI Registry.