Bradley Bibb MD PLLC
Organization Active NPI Rural Health Clinic/Center · Ponca City, OK
NPI 1194572040 · NPPES record last updated Oct 2, 2024
Key facts
- NPI
- 1194572040
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Rural Health Clinic/Center 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
- Organization subpart
- No
Authorized official
- Name
- Monya York
- Title
- Controller
- Phone
- (870) 856-1202
Owners & managing parties with NPI records 4
-
Randi L Davis, APRN
-
Sheri N. Davis, A.P.R.N., FNP-C
-
Mark S Hahn, DO
Other NPIs on the same Medicare enrollment 1
Other NPIs with the same Medicare PAC ID 12
Practitioners 77
-
Megan Lawver, N.P.
-
Linzy Gavin, APRN
-
Mark S Hahn, DO
-
Terri N Moody, APN
-
Kayla Diane Hardesty, P.A-C, PT
-
Chadwick B. Ross, D.O.
-
Amy Casey, APRN
-
Morgan Brittany Shirley, APRN
-
Thomas Frasier Engle, PA-C
-
Christopher Greenhagen, PA-C
-
Chad E Knight, APRN FNP-BC
-
Larreasha Kentoria Adams, APRN
-
Brandy N Anderson, APRN
-
Kirsten Baker, PA-C
-
Jody A Barham, APN
-
Bradley Ray Bibb, MD
-
Shannon Black, FNP-BC
-
Courtney Brashear, APRN
-
James Ryan Carroll, APRN
-
Courtney Linn Cavender, APRN
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 37D2305616 | Bradley Bibb MD PLLC | Certificate of waiver | Dec 31, 2026 |
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled (2 enrollments) in OK
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
- LLC · Proprietary
- Incorporated
- Jul 23, 2008 in AR
- Enrollment address
- 1201 E Hartford Ave
Ponca City, OK 74601-2018
All disclosed owners & managing parties 6
| Name | Role | Since | Share |
|---|---|---|---|
| Mark Hahn |
5% Or Greater Direct Ownership Interest |
May 8, 2025 | |
| Corporate Officer |
May 8, 2025 | ||
| Jared Clifford |
Corporate Officer |
May 8, 2025 | |
| Sheri N Davis |
W-2 Managing Employee |
May 8, 2025 | |
| Monya York |
W-2 Managing Employee |
May 8, 2025 | |
| Operational/Managerial Control |
May 8, 2025 | ||
| Randi L Davis |
W-2 Managing Employee |
May 8, 2025 | |
| Candice M Cartwright |
W-2 Managing Employee |
May 8, 2025 |
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| 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 |
National Provider Directory
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | |||
| Rural Health Clinic/Center | 261QR1300X | Yes |
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
Other providers in Ponca City, OK
- Jenny Lee Boddy
- Steven Wayne Bookout
- Lonna Bouton
- Jessica Bowen
- Tina Marie Bower
- Mona Gay Brenneman
- Janice Kay Brewer-Bell
- Bridgeway
- Bridgeway, Inc.
- Noelle Brien
All providers in Ponca City, OK · Rural Health Clinic/Center in Oklahoma
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 2, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- CMS facility enrollments, All Owners and change-of-ownership files: CCNs, owners and managing parties.
- Provider of Services files (CMS): certification status, beds and related CCNs.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.