Provider Demographics
NPI:1639639321
Name:GREEN COUNTRY INFECTIOUS DISEASE PC
Entity type:Organization
Organization Name:GREEN COUNTRY INFECTIOUS DISEASE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-448-6160
Mailing Address - Street 1:5908 S 298TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-8405
Mailing Address - Country:US
Mailing Address - Phone:918-872-8822
Mailing Address - Fax:918-872-8823
Practice Address - Street 1:421 STONE WOOD DR
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-1026
Practice Address - Country:US
Practice Address - Phone:918-872-8822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-20
Last Update Date:2019-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty