=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114182144
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MCO HEALTH PLANS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/18/2008
-----------------------------------------------------
Last Update Date | 07/18/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1908 12TH AVE NW SUITE B
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-8805
-----------------------------------------------------
Fax | 580-223-8885
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1908 12TH AVE NW SUITE B
-----------------------------------------------------
City | ARDMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73401-1196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-223-8805
-----------------------------------------------------
Fax | 580-223-8885
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TOM COBLE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 580-223-8805
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 2341
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------