Healthcare Provider Details

I. General information

NPI: 1023065695
Provider Name (Legal Business Name): PEDIATRIC AND ADOLESCENT CARE, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 S WHEELING AVE SUITE 300
TULSA OK
74104-5639
US

IV. Provider business mailing address

2000 S WHEELING AVE SUITE 300
TULSA OK
74104-5639
US

V. Phone/Fax

Practice location:
  • Phone: 918-747-7544
  • Fax: 918-747-3952
Mailing address:
  • Phone: 918-747-7544
  • Fax: 918-747-3952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: VALERIE J BAILEY
Title or Position: BUSINESS OFFICE SUPERVISOR
Credential:
Phone: 918-747-7544