1316913510 NPI number — DR. RICKIE CONRADY M.D.

Table of content: DR. RICKIE CONRADY M.D. (NPI 1316913510)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316913510 NPI number — DR. RICKIE CONRADY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CONRADY
Provider First Name:
RICKIE
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1316913510
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 659506
Provider Second Line Business Mailing Address:
SECTION 4142
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78265-9506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-330-7000
Provider Business Mailing Address Fax Number:
405-330-7075

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
225 LILAC DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73034-7287
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-330-7000
Provider Business Practice Location Address Fax Number:
405-280-5661
Provider Enumeration Date:
02/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X , with the licence number:  14650 , 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: 10015790A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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