NPIMap

Organization Active NPI

Bradley Bibb MD PLLC

  • Rural Health Clinic/Center
  • Ponca City, OK
National Provider Identifier
1194572040
Registry record updated Oct 2, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
BRADLEY BIBB MD PLLC
Practice address
1201 E Hartford Ave
Ponca City, OK 74601-2018
Phone
(580) 762-1911
Fax
(580) 762-0887
NPI assigned
Apr 30, 2024
Last updated
Oct 2, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 2, 2024

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

Authorized official

Name
Monya York
Title
Controller
Phone
(870) 856-1202

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary
Family Medicine Physician 207Q00000X

Addresses

Primary practice location

1201 E Hartford Ave
Ponca City, OK 74601-2018

Mailing address

4196 Highway 62 412 Ste a
Hardy, AR 72542-8002

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20240520001147 OK Part B Supplier - Clinic/Group Practice 4789715285 Receives reassigned benefits from 9 practitioners
1 other NPI on this enrollment
Practice locations: El Reno, OK; Ponca City, OK
O20240628002776 OK Part A Provider - Rural Health Clinic 4789715285 Practice locations: Ponca City, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1194572040. Details of each certification follow.

Rural health clinic certification: CCN 373911

Legal name
BRADLEY BIBB MD PLLC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Sep 16, 2024
Last certification
Sep 16, 2024
Ownership / control type
1B
Organization structure
LLCProprietary
Incorporated
Jul 23, 2008 in AR
Enrollment address
1201 E Hartford Ave
Ponca City, OK 74601-2018

Other NPIs with the same Medicare PAC ID 12

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

Other NPIs on the same Medicare enrollment 1

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

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
37D2305616Bradley Bibb MD PLLC1201 E Hartford Ave, Ponca City, OK 74601Certificate of waiverDec 31, 2026

National Provider Directory

National Provider Directory

Ownership & related parties

All disclosed owners & managing parties 6

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

NameRoleSinceShare
Mark Hahn Individual 5% Or Greater Direct Ownership InterestMedical Director May 8, 2025
Corporate OfficerMedical Director May 8, 2025
Jared Clifford Individual Corporate OfficerPresident May 8, 2025
Sheri N Davis Individual W-2 Managing EmployeeVP of Provider Mgmnt May 8, 2025
Monya York Individual W-2 Managing EmployeeDirector Credentialing May 8, 2025
Operational/Managerial ControlDirector Credentialing May 8, 2025
Randi L Davis Individual W-2 Managing EmployeeDirector Provider Mgmnt May 8, 2025
Candice M Cartwright Individual W-2 Managing EmployeeClinic Director May 8, 2025

Owners & managing parties with NPI records 4

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

Practitioners & affiliated clinicians

Practitioners 15

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 15

NPI Registry JSON

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

{
    "created_epoch": "1714435200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1727827200000",
    "number": "1194572040",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4196 HIGHWAY 62 412 STE A",
            "city": "HARDY",
            "state": "AR",
            "postal_code": "725428002"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1201 E HARTFORD AVE",
            "city": "PONCA CITY",
            "state": "OK",
            "postal_code": "746012018",
            "telephone_number": "580-762-1911",
            "fax_number": "580-762-0887"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BRADLEY BIBB MD PLLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2024-04-30",
        "last_updated": "2024-10-02",
        "certification_date": "2024-10-02",
        "status": "A",
        "authorized_official_last_name": "YORK",
        "authorized_official_first_name": "MONYA",
        "authorized_official_title_or_position": "CONTROLLER",
        "authorized_official_telephone_number": "870-856-1202"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Ponca City, OK

Sources for this page

Verify at the official NPI Registry.