Healthcare Provider Details

I. General information

NPI: 1083958300
Provider Name (Legal Business Name): MR. EDWARD BATCHELOR IV
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2012
Last Update Date: 11/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10948 N MAY AVE STE B
OKLAHOMA CITY OK
73120-6224
US

IV. Provider business mailing address

223 W BROADWAY
BLANCHARD OK
73010-5405
US

V. Phone/Fax

Practice location:
  • Phone: 405-555-1212
  • Fax:
Mailing address:
  • Phone: 405-343-1271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: