Healthcare Provider Details

I. General information

NPI: 1215975883
Provider Name (Legal Business Name): TULSA PEDIATRIC AND ADOLESCENT MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 S WHEELING AVE SUITE 304
TULSA OK
74104-5638
US

IV. Provider business mailing address

1919 S WHEELING AVE SUITE 304
TULSA OK
74104-5638
US

V. Phone/Fax

Practice location:
  • Phone: 918-748-7620
  • Fax: 918-748-7647
Mailing address:
  • Phone: 918-748-7620
  • Fax: 918-748-7647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JOEL K GIST
Title or Position: PRESIDENT
Credential: M.D.
Phone: 918-748-7620