Provider Demographics
NPI:1053486431
Name:NORTHERN OKLAHOMA REGIONAL PEDIATRIC CLINIC, PLLC
Entity Type:Organization
Organization Name:NORTHERN OKLAHOMA REGIONAL PEDIATRIC CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:POLLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-765-5569
Mailing Address - Street 1:415 FAIRVIEW AVE
Mailing Address - Street 2:STE. 100
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-1923
Mailing Address - Country:US
Mailing Address - Phone:580-765-5569
Mailing Address - Fax:580-765-2020
Practice Address - Street 1:415 FAIRVIEW AVE
Practice Address - Street 2:STE. 100
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-1923
Practice Address - Country:US
Practice Address - Phone:580-765-5569
Practice Address - Fax:580-765-2020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749170CMedicaid