Provider Demographics
NPI:1295840155
Name:BREAST SURGERY OF TULSA P L L C
Entity Type:Organization
Organization Name:BREAST SURGERY OF TULSA P L L C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LANETTE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-299-8232
Mailing Address - Street 1:PO BOX 21228
Mailing Address - Street 2:DEPT 229
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74121-1228
Mailing Address - Country:US
Mailing Address - Phone:918-299-8232
Mailing Address - Fax:
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:STE G200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4012
Practice Address - Country:US
Practice Address - Phone:918-299-8232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-20
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100749120AMedicaid