Provider Demographics
NPI:1336221688
Name:OKMULGEE PEDIATRICS PC
Entity Type:Organization
Organization Name:OKMULGEE PEDIATRICS PC
Other - Org Name:OKMULGEE PEDIATRICS & FAMILY CARE, L.L.P.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-756-8371
Mailing Address - Street 1:916 E 8TH ST
Mailing Address - Street 2:
Mailing Address - City:OKMULGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74447-4724
Mailing Address - Country:US
Mailing Address - Phone:918-756-8371
Mailing Address - Fax:918-758-3437
Practice Address - Street 1:916 E 8TH ST
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-4724
Practice Address - Country:US
Practice Address - Phone:918-756-8371
Practice Address - Fax:918-758-3437
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100708210BMedicaid