Provider Demographics
NPI:1205829025
Name:EASTERN OKLAHOMA EAR NOSE AND THROAT INC
Entity Type:Organization
Organization Name:EASTERN OKLAHOMA EAR NOSE AND THROAT INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:HEINBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-492-3636
Mailing Address - Street 1:5020 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3307
Mailing Address - Country:US
Mailing Address - Phone:918-429-3636
Mailing Address - Fax:918-494-8915
Practice Address - Street 1:5020 E 68TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3307
Practice Address - Country:US
Practice Address - Phone:918-429-3636
Practice Address - Fax:918-494-8915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1008055608Medicaid