Provider Demographics
NPI:1003099276
Name:CASEY HANNA MD PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:CASEY HANNA MD PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:CASEY
Authorized Official - Last Name:HANNA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-485-5188
Mailing Address - Street 1:PO BOX 894
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74477-0894
Mailing Address - Country:US
Mailing Address - Phone:918-485-5188
Mailing Address - Fax:918-485-5402
Practice Address - Street 1:1202 W CHEROKEE ST STE E
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-4629
Practice Address - Country:US
Practice Address - Phone:918-485-5188
Practice Address - Fax:915-485-5402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21947207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS
OK200522033Medicare PIN