1447382833 NPI number — TRIAD EYE INSTITUTE PLLC

Table of content: (NPI 1447382833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447382833 NPI number — TRIAD EYE INSTITUTE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRIAD EYE INSTITUTE PLLC
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:
6
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:
1447382833
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6140 S MEMORIAL DR
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:
74133-1933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-252-2020
Provider Business Mailing Address Fax Number:
918-307-1983

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3131 MILITARY BLVD
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:
74401-2290
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-687-6600
Provider Business Practice Location Address Fax Number:
918-307-1983
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ABEL
Authorized Official First Name:
MARC
Authorized Official Middle Name:
L
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
918-252-2020

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  731288036 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207W00000X , with the licence number: 731288036 , 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: CO5028 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 490004258 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100738620D , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 490000830 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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