1770684540 NPI number — MICHAEL G JENSON PAC CPP

Table of content: MICHAEL G JENSON PAC CPP (NPI 1770684540)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770684540 NPI number — MICHAEL G JENSON PAC CPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENSON
Provider First Name:
MICHAEL
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PAC CPP
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:
1770684540
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4807 E 91ST ST
Provider Second Line Business Mailing Address:
LB003
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74137-2841
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-502-7246
Provider Business Mailing Address Fax Number:
918-502-7250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6585 SOUTH YALE
Provider Second Line Business Practice Location Address:
SUITE 1110
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74136
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-502-7246
Provider Business Practice Location Address Fax Number:
918-502-7250
Provider Enumeration Date:
09/26/2006

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: 363A00000X , with the licence number:  538 , 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: DA8285 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200070240A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 680535868002 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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