Provider Demographics
NPI:1770862179
Name:ACCESS MEDICAL RIVERSIDE LLC
Entity Type:Organization
Organization Name:ACCESS MEDICAL RIVERSIDE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CANNEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:FERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-260-2093
Mailing Address - Street 1:7020 S. UTICA AVE.
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-7002
Mailing Address - Country:US
Mailing Address - Phone:918-296-7045
Mailing Address - Fax:918-508-5023
Practice Address - Street 1:7020 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3907
Practice Address - Country:US
Practice Address - Phone:918-296-7045
Practice Address - Fax:918-518-5023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-16
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty