Provider Demographics
NPI:1750400230
Name:MIDTOWN DERMATOLOGY LLC
Entity type:Organization
Organization Name:MIDTOWN DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GRETA
Authorized Official - Middle Name:
Authorized Official - Last Name:TERHUNE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-743-4046
Mailing Address - Street 1:2424 E. 21ST STREET
Mailing Address - Street 2:SUITE 340
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114
Mailing Address - Country:US
Mailing Address - Phone:918-728-3100
Mailing Address - Fax:918-728-3376
Practice Address - Street 1:2424 E. 21ST STREET
Practice Address - Street 2:SUITE 340
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114
Practice Address - Country:US
Practice Address - Phone:918-728-3100
Practice Address - Fax:918-728-3376
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251300000X
OK18895207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No251300000XAgenciesLocal Education Agency (LEA)Group - Multi-Specialty
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH7333OtherRAILROAD MEDICARE - PALMETTO GBA
OK=========001OtherBLUE CROSS BLUE SHIELD
OK=========001OtherBLUE CROSS BLUE SHIELD
OKA13163Medicare UPIN