Provider Demographics
NPI:1912165309
Name:WARREN CLINIC SAND SPRINGS SOONERCARE GROUP
Entity Type:Organization
Organization Name:WARREN CLINIC SAND SPRINGS SOONERCARE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:MASON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-488-6687
Mailing Address - Street 1:796 E CHARLES PAGE BLVD
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-8507
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6600 S YALE AVE
Practice Address - Street 2:STE 1400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3310
Practice Address - Country:US
Practice Address - Phone:918-488-6001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WARREN CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100739490UMedicaid