Provider Demographics
NPI:1801002118
Name:ADA OUTPATIENT CLINIC, INC.
Entity Type:Organization
Organization Name:ADA OUTPATIENT CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:YARBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-332-8900
Mailing Address - Street 1:2901 ARLINGTON ST
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2928
Mailing Address - Country:US
Mailing Address - Phone:580-332-8900
Mailing Address - Fax:580-332-9052
Practice Address - Street 1:2901 ARLINGTON ST
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2928
Practice Address - Country:US
Practice Address - Phone:580-332-8900
Practice Address - Fax:580-332-9052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2010-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK600522036Medicare ID - Type Unspecified