1851327464 NPI number — PARKSIDE, INC.

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 1851327464 NPI number — PARKSIDE, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PARKSIDE, INC.
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:
PARKSIDE OUTPATIENT
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:
1851327464
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/31/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1620 E 12TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74120-5407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-582-2131
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1620 E 12TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74120-5407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-582-2131
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
SAUNYA
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
918-582-2131

Provider Taxonomy Codes

  • Taxonomy code: 261QM0850X , with the licence number:  2261 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: 2261 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 283Q00000X , with the licence number: 2261 , 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: 100738360B , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: A00174120 . This is a "CHAMPUS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 000374005-001 . This is a "BC/BS" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100738360C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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