MEDICARE: SOUTHEASTERN OKLAHOMA OUTPATIENT REHAB

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist		OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	441764286001	OTHER	OK	BLUE CROSS

General Provider Information

NPI Number	:	1093709628
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHEASTERN OKLAHOMA OUTPATIENT REHAB

Provider Business Mailing Address
First Line	:	PO BOX 3070
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75504-3070
Country	:	US
Telephone Number	:	903-735-5356
Fax Number	:	903-735-5399

Provider Business Practice Location Address
First Line	:	1425 LINCOLN RD
Second Line	:	SUITE B-3
City	:	IDABEL
State	:	OK
Zip	:	74745-7345
Country	:	US
Telephone Number	:	580-286-4842
Fax Number	:	903-735-5399

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	NANCY BARLOW
Credential	:
Telephone Number	:	903-614-4402

Provider Enumeration Date	:	09/09/2005
Last Update Date	:	07/21/2022

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1922056662 — DR. STEPHEN JEROME KATZ M.D.
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1427101765 — DR. MICHAEL DEWAYNE BROWN JR. D.O.
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Directions to “SOUTHEASTERN OKLAHOMA OUTPATIENT REHAB ” Practice Location

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