1114126976 NPI number — DWAYNE H ATWELL MD PC

Table of content: (NPI 1114126976)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114126976 NPI number — DWAYNE H ATWELL MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DWAYNE H ATWELL MD PC
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:
1114126976
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/16/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
251 SOUTH 37TH STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSKOGEE
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74401-4919
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-683-0121
Provider Business Mailing Address Fax Number:
918-683-6650

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 SOUTH 37TH STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MUSKOGEE
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74401-4919
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-683-0121
Provider Business Practice Location Address Fax Number:
918-683-6650
Provider Enumeration Date:
07/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JONES
Authorized Official First Name:
BRANDI
Authorized Official Middle Name:
L
Authorized Official Title or Position:
INSURANCE CLERK
Authorized Official Telephone Number:
918-683-0121

Provider Taxonomy Codes

  • Taxonomy code: 207Y00000X , with the licence number:  16851 , 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: 100180620A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300522334 . This is a "MEDICARE GROUP" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 0004110411 . This is a "AETNA" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 491607790001 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 040004806 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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