Provider Demographics
NPI:1205864253
Name:PEDIATRIC INTENSIVE CARE SERVICES INC
Entity Type:Organization
Organization Name:PEDIATRIC INTENSIVE CARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHNNY
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:GRIGGS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-947-5557
Mailing Address - Street 1:PO BOX 963135
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0001
Mailing Address - Country:US
Mailing Address - Phone:405-947-8586
Mailing Address - Fax:405-948-6507
Practice Address - Street 1:3300 NW EXPRESSWAY ST
Practice Address - Street 2:#100 3135
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4418
Practice Address - Country:US
Practice Address - Phone:405-947-5557
Practice Address - Fax:405-948-6507
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-29
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========002OtherBCBS