Provider Demographics
NPI:1629018429
Name:EDMOND PHYSICIAN SERVICES LLC
Entity Type:Organization
Organization Name:EDMOND PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PATIENT ACCOUNTING
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-271-8132
Mailing Address - Street 1:PO BOX 744503
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-4503
Mailing Address - Country:US
Mailing Address - Phone:405-271-8132
Mailing Address - Fax:405-271-5006
Practice Address - Street 1:105 S BRYANT AVE STE 105
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-6330
Practice Address - Country:US
Practice Address - Phone:405-715-3102
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200045590AMedicaid
OK900522219Medicare ID - Type Unspecified
OKDQ9190Medicare PIN