NPIMap

Organization Active NPI

Integris Bass Baptist Health Center

Doing business as Integris Health Medical Group Medford

  • Rural Health Clinic/Center
  • Medford, OK
National Provider Identifier
1730180894
Registry record updated Apr 14, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
INTEGRIS BASS BAPTIST HEALTH CENTER
Doing business as
Integris Health Medical Group Medford
Practice address
158 E Sunset Dr
Ste B
Medford, OK 73759-2427
Phone
(580) 395-2319
NPI assigned
Aug 10, 2005
Last updated
Apr 14, 2025By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 14, 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 Physician 207Q00000X NU
Rural Health Clinic/Center 261QR1300X NU Primary

Addresses

Primary practice location

158 E Sunset Dr
Ste B
Medford, OK 73759-2427

Mailing address

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

Other identifiers 3

IdentifierTypeStateIssuer
100755790AMedicaidOK
100755790BMedicaidOK
100699500NMedicaidOK

Other names 1

  • INTEGRIS HEALTH MEDICAL GROUP MEDFORD Doing business as

Medicare participation

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

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20030813000013 OK Part A Provider - Rural Health Clinic 0345151981 Practice locations: Medford, OK
O20031103000717 OK Part B Supplier - Clinic/Group Practice 0345151981 Receives reassigned benefits from 28 practitioners
17 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Medford, OK; Hennessey, OK; Enid, OK

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1730180894. Details of each certification follow.

Rural health clinic certification: CCN 373873

Legal name
INTEGRIS BASS BAPTIST HEALTH CENTER
Doing business as
INTEGRIS HEALTH MEDICAL GROUP MEDFORD
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 7, 2003
Last certification
Sep 19, 2023
Ownership / control type
2B
Organization structure
LLCNon-profit
Enrollment address
158 E Sunset Dr
Ste B
Medford, OK 73759-2431

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

Member of 1

Organizations this organization is a member of, according to the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 22

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
Michael D Landes Individual Contracted Managing EmployeeMD; Oct 28, 2022
Operational/Managerial ControlMedical Director Oct 28, 2022
Donna M Wallace Individual Corporate OfficerAssistant Treasurer Oct 27, 2023
Mark a McCulley Individual Corporate Director Jul 1, 2020
Michael S Jackson Individual Corporate Officer May 1, 2019
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, Non-profit, 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 4

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 7

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.

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": "1744588800000",
    "number": "1730180894",
    "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": "158 E SUNSET DR",
            "address_2": "STE B",
            "city": "MEDFORD",
            "state": "OK",
            "postal_code": "737592427",
            "telephone_number": "580-395-2319"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "INTEGRIS BASS BAPTIST HEALTH CENTER",
        "organizational_subpart": "NO",
        "enumeration_date": "2005-08-10",
        "last_updated": "2025-04-14",
        "certification_date": "2025-04-14",
        "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": "",
            "desc": "Family Medicine",
            "state": "NU",
            "license": null,
            "primary": false
        },
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100755790A",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100755790B",
            "state": "OK"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "100699500N",
            "state": "OK"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "INTEGRIS HEALTH MEDICAL GROUP MEDFORD",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Medford, OK

Sources for this page

Verify at the official NPI Registry.