Healthcare Provider Details

I. General information

NPI: 1376343442
Provider Name (Legal Business Name): MEDWISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2025
Last Update Date: 03/17/2025
Certification Date: 03/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 S MUSKOGEE AVE
TAHLEQUAH OK
74464-5437
US

IV. Provider business mailing address

12902 E 51ST ST
TULSA OK
74134-6712
US

V. Phone/Fax

Practice location:
  • Phone: 918-998-9970
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VII. Legacy identifiers

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

VIII. Authorized Official

Name: DENNIS SIDNEY BLACKSTAD
Title or Position: PRESIDENT
Credential: MD
Phone: 918-605-6582