Healthcare Provider Details

I. General information

NPI: 1104830090
Provider Name (Legal Business Name): GILCREASE MEDICAL CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 S. BRADEN AVE.
TULSA OK
74136
US

IV. Provider business mailing address

7125 S. BRADEN AVE.
TULSA OK
74136
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-8100
  • Fax: 918-481-8195
Mailing address:
  • Phone: 918-481-8100
  • Fax: 918-481-8195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number16665
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number16665
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16665
License Number StateOK

VIII. Authorized Official

Name: DR. GARY ROBERT LEE
Title or Position: OWNER
Credential: M.D.
Phone: 918-381-6326