Provider Demographics
NPI:1043568538
Name:BLUE BAYOU INC
Entity Type:Organization
Organization Name:BLUE BAYOU INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BRONSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-229-3410
Mailing Address - Street 1:100 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73102-8006
Mailing Address - Country:US
Mailing Address - Phone:405-229-3410
Mailing Address - Fax:
Practice Address - Street 1:100 PARK AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-8006
Practice Address - Country:US
Practice Address - Phone:405-229-3410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-15
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12345207QA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Single Specialty