Provider Demographics
NPI:1326674177
Name:PREMIER PEDIATRIC AND ADOLESCENT CARE OF BIXBY
Entity Type:Organization
Organization Name:PREMIER PEDIATRIC AND ADOLESCENT CARE OF BIXBY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-943-5777
Mailing Address - Street 1:5913 E 108TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7057
Mailing Address - Country:US
Mailing Address - Phone:918-853-2710
Mailing Address - Fax:
Practice Address - Street 1:7814 E 121ST ST
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008
Practice Address - Country:US
Practice Address - Phone:918-943-5777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-12
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty