Provider Demographics
NPI:1265703573
Name:STRAUB, MARION C (BHRS)
Entity type:Individual
Prefix:
First Name:MARION
Middle Name:C
Last Name:STRAUB
Suffix:
Gender:M
Credentials:BHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14378 HIGHWAY 32
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:OK
Mailing Address - Zip Code:73439-8133
Mailing Address - Country:US
Mailing Address - Phone:580-624-0624
Mailing Address - Fax:
Practice Address - Street 1:512 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:580-371-3672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid