1477551745 NPI number — GP SURGERY CENTER, LLC

Table of content: RONALD BANUA WIJANGCO RRT (NPI 1306635842)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477551745 NPI number — GP SURGERY CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GP SURGERY CENTER, LLC
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:
6
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:
1477551745
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:
5404 SOUTHWEST LEE BOULEVARD
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
LAWTON
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73505-9521
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-536-7533
Provider Business Mailing Address Fax Number:
580-536-7535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5404 SOUTHWEST LEE BOULEVARD
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
LAWTON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73505-9521
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-536-7533
Provider Business Practice Location Address Fax Number:
580-536-7535
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
REED
Authorized Official First Name:
KATHERINE
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
AUTHORIZED OFFICIAL
Authorized Official Telephone Number:
972-763-3859

Provider Taxonomy Codes

  • Taxonomy code: 261QA1903X , with the licence number:  0027 , 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: 200008100A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490005778 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 000371019001 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 000371019001 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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