1093890352 NPI number — CITY OF WAGONER

Table of content: (NPI 1093890352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093890352 NPI number — CITY OF WAGONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CITY OF WAGONER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093890352
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 406
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAGONER
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74477-0406
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-538-8278
Provider Business Mailing Address Fax Number:
580-628-2273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 SE 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WAGONER
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74467-5726
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-538-8278
Provider Business Practice Location Address Fax Number:
580-628-2273
Provider Enumeration Date:
10/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ROBERTS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
SUPERVISOR
Authorized Official Telephone Number:
800-538-8278

Provider Taxonomy Codes

  • Taxonomy code: 3416L0300X , with the licence number:  EMS014 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 731011975001 . This is a "BCBS PROVIDER NUMBER" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100818530A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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