Healthcare Provider Details

I. General information

NPI: 1619126489
Provider Name (Legal Business Name): BLUE STAR MEDICAL GROUP PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3115 SW 89TH ST
OKLAHOMA CITY OK
73159-7901
US

IV. Provider business mailing address

3115 SW 89TH ST
OKLAHOMA CITY OK
73159-7901
US

V. Phone/Fax

Practice location:
  • Phone: 405-424-5630
  • Fax:
Mailing address:
  • Phone: 405-424-5630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: GLENDA COHRS
Title or Position: ADMINISTRATOR
Credential:
Phone: 405-424-5630