Healthcare Provider Details

I. General information

NPI: 1861650251
Provider Name (Legal Business Name): WARREN CLINIC SOUTH FAMILY MEDICINE SOONERCARE GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 11/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 S YALE AVE STE 1400
TULSA OK
74136-3310
US

IV. Provider business mailing address

10505 E 91ST ST SUITE 110
TULSA OK
74133-5801
US

V. Phone/Fax

Practice location:
  • Phone: 918-488-6001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CATHEY RAE DUPLISSEY
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 918-488-6687