Provider Demographics
NPI:1104039437
Name:GREEN COUNTRY SPORTS PHYSICAL MEDICINE AND REHAB PC
Entity Type:Organization
Organization Name:GREEN COUNTRY SPORTS PHYSICAL MEDICINE AND REHAB PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESEDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SRIKANTH
Authorized Official - Middle Name:K
Authorized Official - Last Name:REDDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-459-9500
Mailing Address - Street 1:8803 S 101ST EAST AVE
Mailing Address - Street 2:SUITE#290
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5726
Mailing Address - Country:US
Mailing Address - Phone:918-459-9500
Mailing Address - Fax:918-459-0995
Practice Address - Street 1:8803 S 101ST EAST AVE
Practice Address - Street 2:SUITE#290
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-5726
Practice Address - Country:US
Practice Address - Phone:918-459-9500
Practice Address - Fax:918-459-0995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-07
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207332081H0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081H0002XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationHospice and Palliative MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKG50662Medicare UPIN