1114276425 NPI number — EASTERN OKLAHOMA MEDICAL CONSULTANTS, 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 1114276425 NPI number — EASTERN OKLAHOMA MEDICAL CONSULTANTS, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN OKLAHOMA MEDICAL CONSULTANTS, 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:
1114276425
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GORE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74435-0479
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-489-5757
Provider Business Mailing Address Fax Number:
918-489-5411

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 NORTH MAIN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GORE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74435-0479
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-489-5757
Provider Business Practice Location Address Fax Number:
918-489-5411
Provider Enumeration Date:
08/31/2012

Additional Information

Authorized Official

Authorized Official Last Name:
KEATHLEY
Authorized Official First Name:
SHELLY
Authorized Official Middle Name:
F
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
918-489-5757

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200454880A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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