1639479348 NPI number — MILESTONE PEDIATRIC CARE, PLLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639479348 NPI number — MILESTONE PEDIATRIC CARE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILESTONE PEDIATRIC CARE, PLLC
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:
MILESTONES PEDIATRIC CARE
Provider Other Organization Name Type Code:
3
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:
1639479348
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3845 S 103RD EAST AVE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74146-2452
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-745-0800
Provider Business Mailing Address Fax Number:
918-745-0028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3863 S 103RD EAST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74146-2443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-745-0800
Provider Business Practice Location Address Fax Number:
918-745-0028
Provider Enumeration Date:
10/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
HENLEY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
AARON
Authorized Official Title or Position:
MANAGER/MEMBER
Authorized Official Telephone Number:
918-745-0800

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  4195 , 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: 200312980A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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