1720165830 NPI number — GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF OWASSO PLLC

Table of content: (NPI 1720165830)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720165830 NPI number — GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF OWASSO PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF OWASSO 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:
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:
1720165830
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4500 S GARNETT RD
Provider Second Line Business Mailing Address:
STE 300
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74146-5229
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-664-9892
Provider Business Mailing Address Fax Number:
918-664-2521

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10502 N 110TH EAST 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:
74055-6655
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-376-8000
Provider Business Practice Location Address Fax Number:
918-664-2521
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WARLICK
Authorized Official First Name:
JESSICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING COORDINATOR
Authorized Official Telephone Number:
918-664-9892

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200100660A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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