Healthcare Provider Details

I. General information

NPI: 1316952112
Provider Name (Legal Business Name): PIC BARTLESVILLE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 02/01/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2334 SE WASHINGTON BLVD STE B&D PIC BARTLESVILLE PLLC
BARTLESVILLE OK
74006-7256
US

IV. Provider business mailing address

PO BOX 1207
MILWAUKEE WI
53201-1207
US

V. Phone/Fax

Practice location:
  • Phone: 918-331-9184
  • Fax: 918-331-9187
Mailing address:
  • Phone: 815-713-2600
  • Fax: 815-654-8020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16429
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number18176
License Number StateOK

VIII. Authorized Official

Name: MS. MONICA KLOSA
Title or Position: DIRECTOR / BILLING SERVICES
Credential:
Phone: 815-713-2621