1942472675 NPI number — TRI-LAKES UROLOGY, INC

Table of content: (NPI 1942472675)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942472675 NPI number — TRI-LAKES UROLOGY, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRI-LAKES UROLOGY, 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:
Provider Other Organization Name Type Code:
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:
1942472675
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 751
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:
73101-0751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-858-2350
Provider Business Mailing Address Fax Number:
405-858-2365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
545 BRANSON LANDING BLVD
Provider Second Line Business Practice Location Address:
SUITE 307
Provider Business Practice Location Address City Name:
BRANSON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65616-4500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-335-7736
Provider Business Practice Location Address Fax Number:
417-334-3038
Provider Enumeration Date:
04/02/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GIVENS
Authorized Official First Name:
JERRY
Authorized Official Middle Name:
SAMUEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-335-7736

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  MDR9B09 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1089490001 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 14360 . This is a "BLUE SHIELD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 152379001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 202355806 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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