| Contacts | Primary Contact | Update | Group Change Request | Dooley, Ryan Dale
340B Compliance Manager
INTEGRIS Health
4058026057 | Yang, Christopher K.
340B Coordinator
INTEGRIS Health
4057952545 | 11/4/2024 8:00 AM |
| Addresses | Billing Address | Update | Recertification | INTEGRIS Bass Baptist Health Center
PO Box 960239
Oklahoma City, OK 73196-0239 | INTEGRIS HEALTH ENID HOSPITAL
PO Box 960239
Oklahoma City, OK 73196-0239 | 8/26/2024 3:56 PM |
| Details | Last Recertification Date | Update | Recertification | 8/20/2023 10:35:03 PM | 8/26/2024 3:56:02 PM | 8/26/2024 3:56 PM |
| Details | Entity Subname | Update | Recertification | INTEGRIS Health Enid Hospital - Sleep Inst. | INTEGRIS HEALTH ENID HOSPITAL - SLEEP MEDICINE | 8/26/2024 3:56 PM |
| Addresses | Main Address | Update | Change Request |
401 South Third, Suite 302
Enid, OK 73703 |
401 South Third St
Suite 302
Enid, OK 73703 | 6/2/2024 3:05 PM |
| Details | Entity Subname | Update | Change Request | INTEGRIS Bass Baptist Health Center - Sleep Inst. | INTEGRIS Health Enid Hospital - Sleep Inst. | 6/2/2024 3:05 PM |
| Details | Entity Name | Update | Change Request | INTEGRIS BASS BAPTIST HEALTH CENTER | INTEGRIS HEALTH ENID HOSPITAL | 5/27/2024 8:50 AM |
| Contacts | Primary Contact | Update | Group Change Request | Wilkinson, Anja
340B Compliance Director
Integris Health
9182316358 | Dooley, Ryan Dale
340B Compliance Manager
INTEGRIS Health
4058026057 | 9/8/2023 7:33 AM |
| Details | Last Recertification Date | Update | Recertification | 9/2/2022 8:59:42 AM | 8/20/2023 10:35:03 PM | 8/20/2023 10:35 PM |
| Contacts | Authorizing Official | Update | Profile Change Request | Lunday, Georg F.
Chief Pharmacy Officer
INTEGRIS Health
4059493039 | Lunday, Georg F.
Chief Pharmacy Officer
INTEGRIS Health
4054014842 | 4/12/2023 1:32 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Wilkinson, Anja
340B Compliance Director
Integris Health
4056446998 | Wilkinson, Anja
340B Compliance Director
Integris Health
9182316358 | 4/4/2023 10:16 AM |
| Contacts | Authorizing Official | Update | Change Request | Hubbard, Brent
Chief Operating Officer
INTEGRIS Health
4059493502 | Lunday, Georg F.
Chief Pharmacy Officer
INTEGRIS Health
4059493039 | 9/9/2022 1:29 PM |
| Details | Last Recertification Date | Update | Recertification | 8/23/2021 7:36:07 AM | 9/2/2022 8:59:42 AM | 9/2/2022 8:59 AM |
| Contacts | Authorizing Official | Update | Change Request | Hammes, Chris
Executive Vice President
INTEGRIS Health System
4059493400 | Hubbard, Brent
Chief Operating Officer
INTEGRIS Health
4059493502 | 6/7/2022 12:14 PM |
| Details | Last Recertification Date | Update | Recertification | 9/3/2020 3:54:25 PM | 8/23/2021 7:36:07 AM | 8/23/2021 7:36 AM |
| Medicaid Billing | NPI: Number | Insert | Recertification | | 1144236571 | 9/3/2020 3:54 PM |
| Medicaid Billing | NPI: State | Insert | Recertification | | OK | 9/3/2020 3:54 PM |
| Details | Last Recertification Date | Update | Recertification | 8/29/2019 11:39:14 AM | 9/3/2020 3:54:25 PM | 9/3/2020 3:54 PM |
| Contacts | Authorizing Official | Update | Change Request | Mathew, Finny
President
INTEGRIS Bass Baptist Health Center
5805481100 | Hammes, Chris
Executive Vice President
INTEGRIS Health System
4059493400 | 2/3/2020 3:26 PM |
| Contacts | Primary Contact | Update | Profile Change Request | Wilkinson, Anja Dawn
340B Compliance Director
Integris Health
4056446998 | Wilkinson, Anja
340B Compliance Director
Integris Health
4056446998 | 10/17/2019 11:56 AM |
| Contacts | Primary Contact | Update | Change Request | Tennell, Kathryn Alice
Director of pharmacy
INTEGRIS Bass Baptist Health Center
5805481388 | Wilkinson, Anja Dawn
340B Compliance Director
Integris Health
4056446998 | 8/30/2019 8:58 AM |
| Details | Last Recertification Date | Update | Recertification | 8/28/2018 9:42:30 AM | 8/29/2019 11:39:14 AM | 8/29/2019 11:39 AM |
| Contacts | Primary Contact | Update | Change Request | Bui, Kim
System Manager, 340B Compliance
INTEGRIS Health
4056446998 | Tennell, Kathryn Alice
Director of pharmacy
INTEGRIS Bass Baptist Health Center
5805481388 | 8/29/2018 11:13 AM |
| Details | Last Recertification Date | Update | Recertification | 11/15/2017 12:39:16 PM | 8/28/2018 9:42:30 AM | 8/28/2018 9:42 AM |
| Contacts | Authorizing Official | Update | Change Request | Dietz, Brian
President
INTEGRIS Bass Baptist Health Center
5805481100 | Mathew, Finny
President
INTEGRIS Bass Baptist Health Center
5805481100 | 1/17/2018 7:39 AM |
| Contacts | Primary Contact | Update | Change Request | King, Eric
System Manager, 340B Compliance
INTEGRIS Health
4056367813 | Bui, Kim
System Manager, 340B Compliance
INTEGRIS Health
4056446998 | 1/4/2018 6:24 PM |
| Contacts | Primary Contact | Insert | Recertification | | King, Eric
System Manager, 340B Compliance
INTEGRIS Health
4056367813 | 11/15/2017 12:39 PM |
| Details | Last Recertification Date | Update | Recertification | 8/15/2016 12:00:00 AM | 11/15/2017 12:39:16 PM | 11/15/2017 12:39 PM |
| Contacts | Authorizing Official | Update | AO Change Request | Herrman, Edward
President
5805481100 | Dietz, Brian
President
INTEGRIS Bass Baptist Health Center
5805481100 | 11/13/2017 12:54 PM |
| Details | Entity Name | Update | Change Request | BASS BAPTIST HEALTH CENTER | INTEGRIS BASS BAPTIST HEALTH CENTER | 10/12/2017 2:36 PM |
| Contacts | Signed By | Update | Change Request | Herrman, Edward
President
5805481100 | Herrman, Edward
President
INTEGRIS Bass Baptist Health Center
5805481100 | 10/12/2017 10:37 AM |
| Addresses | Main Address | Insert | | |
401 South Third, Suite 302
Enid, OK 73703 | 5/2/2017 4:59 PM |
| Addresses | Billing Address | Insert | | | INTEGRIS Bass Baptist Health Center
PO Box 960239
Oklahoma City, OK 73196-0239 | 5/2/2017 4:59 PM |
| Contacts | Authorizing Official | Insert | | | Herrman, Edward
President
5805481100 | 5/2/2017 4:59 PM |
| Contacts | Signed By | Insert | | | Herrman, Edward
President
5805481100 | 5/2/2017 4:59 PM |
| Details | Last Recertification Date | Update | | 8/5/2015 12:00:00 AM | 8/15/2016 12:00:00 AM | 8/15/2016 2:11 PM |
| Details | Last Recertification Date | Update | | | 8/5/2015 12:00:00 AM | 8/5/2015 3:59 PM |
| Dates | Participating Approval Date | Update | | | 5/14/2015 12:00:00 AM | 5/14/2015 3:26 PM |
| Details | State | Update | | Pending | Active | 5/14/2015 3:26 PM |
| Dates | Start Date | Update | | | 7/1/2015 12:00:00 AM | 5/14/2015 3:26 PM |
| Details | 340B ID | Update | | OUTPATIENT_ONLINE_REG_50981 | DSH370016B | 4/21/2015 10:03 AM |
| Details | 340B ID | Update | | | OUTPATIENT_ONLINE_REG_50981 | 4/9/2015 3:55 PM |
| Medicaid Billing | Medicaid: Is Primary | Insert | | | False | 4/9/2015 3:55 PM |
| Medicaid Billing | Medicaid: Number | Insert | | | 100699500A | 4/9/2015 3:55 PM |
| Medicaid Billing | Medicaid: State | Insert | | | OK | 4/9/2015 3:55 PM |
| Details | Last Recertification Date | Insert | | | | 4/9/2015 3:55 PM |
| Details | Grant Number | Insert | | | | 4/9/2015 3:55 PM |
| Details | 340B ID | Insert | | | | 4/9/2015 3:55 PM |
| Details | Is Authorizing Official EHB Data | Insert | | | | 4/9/2015 3:55 PM |
| Dates | Last Date That 340B Drugs Purchased | Insert | | | | 4/9/2015 3:55 PM |
| Details | Medicare Provider Number | Insert | | | 370016 | 4/9/2015 3:55 PM |
| Details | Entity Name | Insert | | | BASS BAPTIST HEALTH CENTER | 4/9/2015 3:55 PM |
| Details | Program Code | Insert | | | DSH | 4/9/2015 3:55 PM |
| Details | Entity Subname | Insert | | | INTEGRIS Bass Baptist Health Center - Sleep Inst. | 4/9/2015 3:55 PM |
| Dates | Participating Approval Date | Insert | | | | 4/9/2015 3:55 PM |
| Details | State | Insert | | | Pending | 4/9/2015 3:55 PM |
| Dates | Registration Date | Insert | | | 4/9/2015 12:00:00 AM | 4/9/2015 3:55 PM |
| Dates | Signed By Date | Insert | | | 4/9/2015 12:00:00 AM | 4/9/2015 3:55 PM |
| Dates | Start Date | Insert | | | | 4/9/2015 3:55 PM |
| Terminations | Termination Comments | Insert | | | | 4/9/2015 3:55 PM |
| Terminations | Termination Date | Insert | | | | 4/9/2015 3:55 PM |
| Terminations | Termination Effective Date | Insert | | | | 4/9/2015 3:55 PM |
| Terminations | Termination Reason | Insert | | | | 4/9/2015 3:55 PM |