Provider Demographics
NPI:1588620140
Name:GREEN COUNTRY RADIOLOGY, INC
Entity Type:Organization
Organization Name:GREEN COUNTRY RADIOLOGY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:KNEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-664-9892
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-664-9892
Mailing Address - Fax:918-664-2521
Practice Address - Street 1:129 N KENTUCKY ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-4211
Practice Address - Country:US
Practice Address - Phone:918-664-9892
Practice Address - Fax:918-664-2521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100742290AMedicaid
OKCS7021Medicare PIN
OK100742290AMedicaid