Provider Demographics
NPI:1790155562
Name:CALDWELL MEDICAL GROUP OF NORTH TULSA LLC
Entity Type:Organization
Organization Name:CALDWELL MEDICAL GROUP OF NORTH TULSA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KAMMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:CALDWELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-485-0291
Mailing Address - Street 1:8014 S 101ST EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-4579
Mailing Address - Country:US
Mailing Address - Phone:918-949-9910
Mailing Address - Fax:
Practice Address - Street 1:8014 S 101ST EAST AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-4579
Practice Address - Country:US
Practice Address - Phone:918-949-9910
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty