1568552065 NPI number — R. ERIK EDENS MD

Table of content: R. ERIK EDENS MD (NPI 1568552065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568552065 NPI number — R. ERIK EDENS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDENS
Provider First Name:
R.
Provider Middle Name:
ERIK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1568552065
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 EVERETT DR
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:
73104-5047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-271-5530
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 EVERETT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73104-5047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-271-5530
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/13/2006

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: 2080P0202X , with the licence number:  63123 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: 32079 , registered in the state of IA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: E-4154 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080P0202X , with the licence number: 38516 , 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: 154650001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 2161414 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 63123 . This is a "MINNESOTA MEDICAL LICENSE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 29686 . This is a "WELLMARK BCBS" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".