1578760021 NPI number — AHS OKLAHOMA PHYSICIAN GROUP, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578760021 NPI number — AHS OKLAHOMA PHYSICIAN GROUP, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AHS OKLAHOMA PHYSICIAN GROUP, LLC
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:
1578760021
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1145 S UTICA AVE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74104-4000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-579-3825
Provider Business Mailing Address Fax Number:
918-579-1262

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10512 NORTH 110TH E. AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OWASSO
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74055
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-272-1172
Provider Business Practice Location Address Fax Number:
918-272-7475
Provider Enumeration Date:
06/28/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DENNING
Authorized Official First Name:
EARL
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
918-579-1000

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  18817 , 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)





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