Provider Demographics
NPI:1184744203
Name:AERIE FAMILY WELLNESS & MEDICAL GROUP PC
Entity type:Organization
Organization Name:AERIE FAMILY WELLNESS & MEDICAL GROUP PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:VERNON
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:918-836-6454
Mailing Address - Street 1:3242 E ADMIRAL PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74110-5536
Mailing Address - Country:US
Mailing Address - Phone:918-836-6454
Mailing Address - Fax:918-836-6455
Practice Address - Street 1:3242 E ADMIRAL PL
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74110-5536
Practice Address - Country:US
Practice Address - Phone:918-836-6454
Practice Address - Fax:918-836-6455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK9483207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1316981004OtherNPI
OKD428443Medicare UPIN