Provider Demographics
NPI:1710973938
Name:KENNETH DALE PRIEST MD PC
Entity Type:Organization
Organization Name:KENNETH DALE PRIEST MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MELENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NACHIMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-775-9350
Mailing Address - Street 1:PO BOX 272606
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73137-2606
Mailing Address - Country:US
Mailing Address - Phone:405-775-9350
Mailing Address - Fax:405-775-9360
Practice Address - Street 1:3705 W MEMORIAL RD
Practice Address - Street 2:SUITE 302
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1512
Practice Address - Country:US
Practice Address - Phone:405-775-9350
Practice Address - Fax:405-775-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-22
Last Update Date:2011-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19107207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKP00118819OtherRR/MEDICARE
OK100744690AMedicaid
OK4647871OtherAETNA
OK358460300OtherDOL
OKDB6320OtherMEDICARE RR GROUP
OKP00118819OtherRR/MEDICARE
OK100744690AMedicaid
G04630Medicare UPIN