Provider Demographics
NPI:1831599737
Name:RENAISSANCE MEDICAL OF OKLAHOMA, P.C.
Entity type:Organization
Organization Name:RENAISSANCE MEDICAL OF OKLAHOMA, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHESTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:479-434-4948
Mailing Address - Street 1:PO BOX 35746
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74153-0746
Mailing Address - Country:US
Mailing Address - Phone:479-434-4948
Mailing Address - Fax:
Practice Address - Street 1:8014 SOUTH 101 EAST AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133
Practice Address - Country:US
Practice Address - Phone:479-434-4948
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-27
Last Update Date:2014-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty