1760655773 NPI number — EDMOND AM CLINIC LLC

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 1760655773 NPI number — EDMOND AM CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EDMOND AM CLINIC 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:
EDMOND AM CLINIC
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:
1760655773
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 269083
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73126-9083
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-216-3993
Provider Business Mailing Address Fax Number:
405-216-3992

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1714 S KELLY AVE
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:
73013-3624
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-216-3993
Provider Business Practice Location Address Fax Number:
405-216-3992
Provider Enumeration Date:
04/10/2008

Additional Information

Authorized Official

Authorized Official Last Name:
BUFFINGTON
Authorized Official First Name:
BILL
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
405-216-3993

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  N/A , 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: 200134140A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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