1245209113 NPI number — LAURA BILBRUCK M.D.

Table of content: LAURA BILBRUCK M.D. (NPI 1245209113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245209113 NPI number — LAURA BILBRUCK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BILBRUCK
Provider First Name:
LAURA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1245209113
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1515 N HARVARD AVE
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74115-4957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-832-6049
Provider Business Mailing Address Fax Number:
918-832-6055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 W BOISE CIR
Provider Second Line Business Practice Location Address:
SUITE 160
Provider Business Practice Location Address City Name:
BROKEN ARROW
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74012-4906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-994-9160
Provider Business Practice Location Address Fax Number:
918-293-3169
Provider Enumeration Date:
03/14/2006

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: 207R00000X , with the licence number:  20265 , 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: 100229790A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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