1083626246 NPI number — UNIVERSITY OF OKLAHOMA HEALTH SCIEN CTR COL OF MED ENID FAM MED

Table of content: (NPI 1083626246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083626246 NPI number — UNIVERSITY OF OKLAHOMA HEALTH SCIEN CTR COL OF MED ENID FAM MED

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UNIVERSITY OF OKLAHOMA HEALTH SCIEN CTR COL OF MED ENID FAM MED
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:
ENID FAMILY MEDICINE
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:
1083626246
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/16/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 S MADISON ST
Provider Second Line Business Mailing Address:
SUITE 304
Provider Business Mailing Address City Name:
ENID
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73701-7273
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-242-1300
Provider Business Mailing Address Fax Number:
580-237-7913

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 S MADISON ST
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
ENID
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73701-7273
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-242-1300
Provider Business Practice Location Address Fax Number:
580-237-7913
Provider Enumeration Date:
08/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
PONTIOUS
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PROFESSOR DIRECTOR
Authorized Official Telephone Number:
580-242-1300

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  261QM2500X , 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: 1164478590 . This is a "DR. MARGO SHORT NPI #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 1457398141 . This is a "DR. PONTIOUS NPI #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".