MEDICARE: MR. TOM EDMUND KNUDSEN

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	104100000X	Social Worker		OK

General Provider Information

NPI Number	:	1407234073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. TOM EDMUND KNUDSEN

Provider Business Mailing Address
First Line	:	923 NE 18TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-8203
Country	:	US
Telephone Number	:	405-973-6135
Fax Number	:

Provider Business Practice Location Address
First Line	:	923 NE 18TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73105-8203
Country	:	US
Telephone Number	:	405-973-6135
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2015
Last Update Date	:	05/14/2015

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