Provider Demographics
NPI:1801146782
Name:PHYSICIAN PREFERRED MEDICAL, LLC
Entity type:Organization
Organization Name:PHYSICIAN PREFERRED MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:ORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-206-1313
Mailing Address - Street 1:3300 NW 56TH ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4538
Mailing Address - Country:US
Mailing Address - Phone:855-203-0681
Mailing Address - Fax:405-213-1554
Practice Address - Street 1:3300 NW 56TH ST
Practice Address - Street 2:101
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4538
Practice Address - Country:US
Practice Address - Phone:855-203-0681
Practice Address - Fax:405-213-1554
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2016-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200497520AMedicaid