Healthcare Provider Details

I. General information

NPI: 1730993460
Provider Name (Legal Business Name): MEDWISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2025
Last Update Date: 02/04/2025
Certification Date: 02/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 N 9TH ST
BROKEN ARROW OK
74012-2897
US

IV. Provider business mailing address

12902 E 51ST ST
TULSA OK
74134-6712
US

V. Phone/Fax

Practice location:
  • Phone: 918-727-2850
  • Fax:
Mailing address:
  • Phone: 918-994-3476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DENNIS SIDNEY BLACKSTAD
Title or Position: PRESIDENT
Credential: MD
Phone: 918-605-6582