Provider Demographics
NPI:1811996861
Name:GRAND LAKE REGIONAL CARDIOLOGY SERVICES LLC
Entity type:Organization
Organization Name:GRAND LAKE REGIONAL CARDIOLOGY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:CALLICOAT
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:918-786-7667
Mailing Address - Street 1:PO BOX 452438
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74345-2438
Mailing Address - Country:US
Mailing Address - Phone:918-786-1070
Mailing Address - Fax:918-786-7699
Practice Address - Street 1:1001 E 18TH ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-2907
Practice Address - Country:US
Practice Address - Phone:918-786-1070
Practice Address - Fax:918-786-7699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional CardiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200046050AMedicaid
OK400522287Medicare ID - Type Unspecified