1316952112 NPI number — PIC BARTLESVILLE, PLLC

Table of content: (NPI 1316952112)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316952112 NPI number — PIC BARTLESVILLE, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PIC BARTLESVILLE, 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:
PIC BARTLESVILLE, PLLC
Provider Other Organization Name Type Code:
5
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:
1316952112
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1207
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILWAUKEE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53201-1207
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-713-2600
Provider Business Mailing Address Fax Number:
815-654-8020

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2334 SE WASHINGTON BLVD STE B&D
Provider Second Line Business Practice Location Address:
PIC BARTLESVILLE PLLC
Provider Business Practice Location Address City Name:
BARTLESVILLE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74006-7256
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-331-9184
Provider Business Practice Location Address Fax Number:
918-331-9187
Provider Enumeration Date:
07/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KLOSA
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR / BILLING SERVICES
Authorized Official Telephone Number:
815-713-2621

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  16429 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , with the licence number: 18176 , 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: 200117320A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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