Healthcare Provider Details

I. General information

NPI: 1083774236
Provider Name (Legal Business Name): TULSA COLON AND RECTAL SURGERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4735 E 91ST 200
TULSA OK
74137-2804
US

IV. Provider business mailing address

4735 E 91ST 200
TULSA OK
74137-2804
US

V. Phone/Fax

Practice location:
  • Phone: 918-794-4788
  • Fax: 918-794-4789
Mailing address:
  • Phone: 918-794-4788
  • Fax: 918-794-4789

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT A FENGLER
Title or Position: SECRETARY TREASURER
Credential: MD
Phone: 918-294-4788