MEDICARE: WESTERN OKLAHOMA ENT, PLLC

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	207Y00000X	Otolaryngology Physician	24331	OK

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	DE9071	OTHER	OK	RAILROAD MEDICARE

General Provider Information

NPI Number	:	1245394949
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN OKLAHOMA ENT, PLLC

Provider Business Mailing Address
First Line	:	1710 W 3RD ST
Second Line	:	SUITE 102
City	:	ELK CITY
State	:	OK
Zip	:	73644-5159
Country	:	US
Telephone Number	:	580-225-5365
Fax Number	:	580-225-2174

Provider Business Practice Location Address
First Line	:	1710 W 3RD ST
Second Line	:	SUITE 102
City	:	ELK CITY
State	:	OK
Zip	:	73644-5159
Country	:	US
Telephone Number	:	580-225-5365
Fax Number	:	580-225-2174

Authorized Official
Title or Position	:	PHYSICIAN OWNER
Name	:	CHENG H PAN
Credential	:	MD
Telephone Number	:	580-225-5365

Provider Enumeration Date	:	12/20/2006
Last Update Date	:	09/24/2007

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