Provider Demographics
NPI:1871820175
Name:ENID UROLOGY ASSOCIATES
Entity Type:Organization
Organization Name:ENID UROLOGY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JARRETT
Authorized Official - Middle Name:D
Authorized Official - Last Name:KRUSKA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-233-3230
Mailing Address - Street 1:615 E OKLAHOMA AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:ENID
Mailing Address - State:OK
Mailing Address - Zip Code:73701-5951
Mailing Address - Country:US
Mailing Address - Phone:580-233-3230
Mailing Address - Fax:580-233-0698
Practice Address - Street 1:6401 PATTERSON PKWY
Practice Address - Street 2:
Practice Address - City:ARKANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:67005-5701
Practice Address - Country:US
Practice Address - Phone:580-233-3230
Practice Address - Fax:580-233-0698
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ENID UROLOGY ASSOCIATES, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-11-06
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0434000208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0361060001OtherMEDICARE DME
OK200057980AMedicaid
OK243515903Medicare PIN
OK200057980AMedicaid