Provider Demographics
NPI:1568826725
Name:PEDIATRIC CARE OF SAPULPA
Entity Type:Organization
Organization Name:PEDIATRIC CARE OF SAPULPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-745-0800
Mailing Address - Street 1:615 S MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SAPULPA
Mailing Address - State:OK
Mailing Address - Zip Code:74066-4635
Mailing Address - Country:US
Mailing Address - Phone:918-745-0800
Mailing Address - Fax:918-745-0028
Practice Address - Street 1:615 S MISSION ST
Practice Address - Street 2:
Practice Address - City:SAPULPA
Practice Address - State:OK
Practice Address - Zip Code:74066-4635
Practice Address - Country:US
Practice Address - Phone:918-745-0800
Practice Address - Fax:918-745-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-13
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty