Provider Demographics
NPI:1114336534
Name:EAST TULSA MEDICAL GROUP
Entity Type:Organization
Organization Name:EAST TULSA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:A
Authorized Official - Last Name:BARENTINE
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:918-437-6830
Mailing Address - Street 1:11445 E 20TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74128-6421
Mailing Address - Country:US
Mailing Address - Phone:918-437-6830
Mailing Address - Fax:918-437-6171
Practice Address - Street 1:11445 E 20TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74128-6421
Practice Address - Country:US
Practice Address - Phone:918-437-6830
Practice Address - Fax:918-437-6171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-11
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1567207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty