Healthcare Provider Details

I. General information

NPI: 1619036035
Provider Name (Legal Business Name): THE PEDIATRIC GROUP, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 NW 56TH ST SUITE 400
OKLAHOMA CITY OK
73112-4479
US

IV. Provider business mailing address

3330 NW 56TH ST SUITE 400
OKLAHOMA CITY OK
73112-4479
US

V. Phone/Fax

Practice location:
  • Phone: 405-945-4220
  • Fax: 405-945-4893
Mailing address:
  • Phone: 405-945-4220
  • Fax: 405-945-4893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: COLLEEN DOOLEY
Title or Position: PARTNER
Credential: M.D.
Phone: 405-945-4220