Provider Demographics
NPI:1720274699
Name:TRACEY W. CHILDERS, D.O. P.C.
Entity Type:Organization
Organization Name:TRACEY W. CHILDERS, D.O. P.C.
Other - Org Name:CHILDERS MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:W
Authorized Official - Last Name:CHILDERS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-453-1234
Mailing Address - Street 1:1203 E ROSS BYP
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4133
Mailing Address - Country:US
Mailing Address - Phone:918-453-1234
Mailing Address - Fax:918-453-9107
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4188
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:918-453-9107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3296207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200000030AMedicaid
OK200000030AMedicaid