1043359813 NPI number — BRIAN EUGENE LOVELACE M.D.

Table of content: BERLINDA A RETLAND PMHNP (NPI 1548726607)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043359813 NPI number — BRIAN EUGENE LOVELACE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LOVELACE
Provider First Name:
BRIAN
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1043359813
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4802 S 109TH EAST AVE
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:
74146-5822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-392-1400
Provider Business Mailing Address Fax Number:
918-392-1488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4812 S 109TH EAST AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74146-5826
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-392-1400
Provider Business Practice Location Address Fax Number:
918-236-4501
Provider Enumeration Date:
02/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  23525 , 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: 200196160A . This is a "MEDICAID" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: OK400474 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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