1043460694 NPI number — URGENT CARE OF GREEN COUNTRY PLLC

Table of content: (NPI 1043460694)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043460694 NPI number — URGENT CARE OF GREEN COUNTRY PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
URGENT CARE OF GREEN COUNTRY 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:
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:
1043460694
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1044
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OWASSO
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74055-1044
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-343-6000
Provider Business Mailing Address Fax Number:
918-343-6251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4115 REDDEN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRYOR
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74361-9192
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-825-7555
Provider Business Practice Location Address Fax Number:
918-825-7556
Provider Enumeration Date:
09/19/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
KOVACS
Authorized Official First Name:
STEPHEN
Authorized Official Middle Name:
ROBERT
Authorized Official Title or Position:
PARTNER/CO OWNER
Authorized Official Telephone Number:
918-274-8555

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X , 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: 200094640F . This is a "MEDICAID DME" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 7835422 . This is a "AETNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200094640D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".