Provider Demographics
NPI:1720039415
Name:OB-GYN OF GREEN COUNTRY
Entity Type:Organization
Organization Name:OB-GYN OF GREEN COUNTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:MS
Authorized Official - First Name:TANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:STUTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:918-825-4800
Mailing Address - Street 1:14 S VANN ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-3613
Mailing Address - Country:US
Mailing Address - Phone:918-825-4800
Mailing Address - Fax:918-825-4809
Practice Address - Street 1:14 S VANN ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-3613
Practice Address - Country:US
Practice Address - Phone:918-825-4800
Practice Address - Fax:918-825-4809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0071260363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTAX ID #
OKP55041Medicare UPIN