Healthcare Provider Details

I. General information

NPI: 1194895441
Provider Name (Legal Business Name): EEG CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E DOWNING
TAHLEQUAH OK
74465
US

IV. Provider business mailing address

PO BOX 54603 EEG CORPORATION HAROLD E GOLDMAN
TULSA OK
74155-0603
US

V. Phone/Fax

Practice location:
  • Phone: 918-743-4799
  • Fax: 918-743-4167
Mailing address:
  • Phone: 918-743-4799
  • Fax: 918-743-4167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number7148
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier046046
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerKS BCBS
# 2
Identifier028207163003
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerOK BCBS

VIII. Authorized Official

Name: HAROLD EARL GOLDMAN
Title or Position: PRESIDENT
Credential: MD
Phone: 918-743-4799