Healthcare Provider Details

I. General information

NPI: 1114283025
Provider Name (Legal Business Name): NORTHEAST OKLAHOMA PHYSICIAN NETWORK INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 E LANSING ST
BROKEN ARROW OK
74012-2429
US

IV. Provider business mailing address

2408 E 81ST ST STE 300
TULSA OK
74137-4200
US

V. Phone/Fax

Practice location:
  • Phone: 918-258-9990
  • Fax: 918-994-4277
Mailing address:
  • Phone: 918-477-5049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD FERGUSON
Title or Position: CEO
Credential:
Phone: 918-477-5049