Provider Demographics
NPI:1457468464
Name:TULSA MEDICAL LABORATORY, LLC
Entity Type:Organization
Organization Name:TULSA MEDICAL LABORATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:RICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:GILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-712-5571
Mailing Address - Street 1:2738 E 51ST ST
Mailing Address - Street 2:SUITE 290
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74105-6231
Mailing Address - Country:US
Mailing Address - Phone:918-712-5571
Mailing Address - Fax:918-747-7831
Practice Address - Street 1:6565 S YALE AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8378
Practice Address - Country:US
Practice Address - Phone:918-712-5571
Practice Address - Fax:918-747-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK37D1002749207ZP0102X, 291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100707130AMedicaid
OK100707130AMedicaid