Healthcare Provider Details

I. General information

NPI: 1639639321
Provider Name (Legal Business Name): GREEN COUNTRY INFECTIOUS DISEASE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

421 STONE WOOD DR
BROKEN ARROW OK
74012-1026
US

IV. Provider business mailing address

5908 S 298TH EAST AVE
BROKEN ARROW OK
74014-8405
US

V. Phone/Fax

Practice location:
  • Phone: 918-872-8822
  • Fax:
Mailing address:
  • Phone: 918-872-8822
  • Fax: 918-872-8823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State

VIII. Authorized Official

Name: JANICE L BRACKEN
Title or Position: CREDENTIALING
Credential:
Phone: 918-448-6160