Provider Demographics
NPI:1356339659
Name:REDBUD PHYSICAL REHABILITATION PC
Entity type:Organization
Organization Name:REDBUD PHYSICAL REHABILITATION PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HUMAN RESOURCES
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-622-4126
Mailing Address - Street 1:4812 E 33RD ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2038
Mailing Address - Country:US
Mailing Address - Phone:918-622-4126
Mailing Address - Fax:918-270-2398
Practice Address - Street 1:4008 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6017
Practice Address - Country:US
Practice Address - Phone:918-622-4278
Practice Address - Fax:918-622-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200034500HMedicaid
OK700522061OtherMEDICARE
OK200034500AMedicaid
CJ4389OtherMEDICARE RAILROAD
OK200034500EMedicaid
OK200034500BMedicaid
OK200034500FMedicaid
OK200034500IMedicaid
OK200034500AOtherMEDICAID LEGACY
OK200034500DMedicaid
OK200034500CMedicaid
OK200034500GMedicaid
OK200034500BMedicaid
OK200034500BMedicaid