Provider Demographics
NPI:1659738953
Name:ALTUS MINOR EMERGENCY & FAMILY PRACTICE
Entity Type:Organization
Organization Name:ALTUS MINOR EMERGENCY & FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:
Authorized Official - Last Name:MOSS
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:580-318-0229
Mailing Address - Street 1:916 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-3118
Mailing Address - Country:US
Mailing Address - Phone:580-318-0229
Mailing Address - Fax:580-480-0044
Practice Address - Street 1:916 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-3118
Practice Address - Country:US
Practice Address - Phone:580-318-0229
Practice Address - Fax:580-480-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-19
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty