Provider Demographics
NPI:1114283025
Name:NORTHEAST OKLAHOMA PHYSICIAN NETWORK INC
Entity Type:Organization
Organization Name:NORTHEAST OKLAHOMA PHYSICIAN NETWORK INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FERGUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-477-5049
Mailing Address - Street 1:2408 E 81ST ST
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-4200
Mailing Address - Country:US
Mailing Address - Phone:918-477-5049
Mailing Address - Fax:
Practice Address - Street 1:1130 E LANSING ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-2429
Practice Address - Country:US
Practice Address - Phone:918-258-9990
Practice Address - Fax:918-994-4277
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-04
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty