1871863258 NPI number — OKLAHOMA SENIOR PODIATRY SERVICES, P.C.

Table of content: (NPI 1871863258)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871863258 NPI number — OKLAHOMA SENIOR PODIATRY SERVICES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA SENIOR PODIATRY SERVICES, P.C.
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:
AGGEUS OKLAHOMA PODIATRY SERVICES, P.C.
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:
1871863258
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 S RIVERSIDE PLZ
Provider Second Line Business Mailing Address:
STE 19 EAST
Provider Business Mailing Address City Name:
CHICAGO
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60606-3728
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
773-770-0140
Provider Business Mailing Address Fax Number:
312-277-6757

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3208 BRUSH CREEK RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73120-1852
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-216-5518
Provider Business Practice Location Address Fax Number:
312-277-6757
Provider Enumeration Date:
01/03/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
K.
Authorized Official Title or Position:
OWNER/PRESIDENT
Authorized Official Telephone Number:
866-216-5518

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200444490A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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