Provider Demographics
NPI:1194185090
Name:PATHWAYS MEDICAL LLC
Entity Type:Organization
Organization Name:PATHWAYS MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ZACHORY
Authorized Official - Middle Name:
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:LPC, LADC
Authorized Official - Phone:405-607-4041
Mailing Address - Street 1:13707 FAIRHILL AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013
Mailing Address - Country:US
Mailing Address - Phone:405-607-4041
Mailing Address - Fax:405-463-0090
Practice Address - Street 1:13707 FAIRHILL AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013
Practice Address - Country:US
Practice Address - Phone:405-607-4041
Practice Address - Fax:405-463-0090
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-04
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200640210AMedicaid