Provider Demographics
NPI:1174684765
Name:BRIAN BIRDWELL MD PC
Entity Type:Organization
Organization Name:BRIAN BIRDWELL MD PC
Other - Org Name:BIRDWELL-FERRIS CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:G
Authorized Official - Last Name:BIRDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD,
Authorized Official - Phone:580-248-9966
Mailing Address - Street 1:1930 NW FERRIS AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-5626
Mailing Address - Country:US
Mailing Address - Phone:580-248-9966
Mailing Address - Fax:580-248-6458
Practice Address - Street 1:1930 NW FERRIS AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-5626
Practice Address - Country:US
Practice Address - Phone:580-248-9966
Practice Address - Fax:580-248-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK13900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100824240AMedicaid
OK300522166Medicare PIN