Healthcare Provider Details

I. General information

NPI: 1528291507
Provider Name (Legal Business Name): MISSION PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2009
Last Update Date: 08/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 S PEORIA AVE SUITE 101
TULSA OK
74105-2003
US

IV. Provider business mailing address

3220 S PEORIA AVE SUITE 101
TULSA OK
74105-2003
US

V. Phone/Fax

Practice location:
  • Phone: 877-228-4951
  • Fax: 918-489-5620
Mailing address:
  • Phone: 877-228-4951
  • Fax: 918-489-5620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WILLIAM R ANDERSON
Title or Position: OFFICER
Credential: DO
Phone: 877-228-4951