=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134298698
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | REGIONAL DERMATOLOGY P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/07/2006
-----------------------------------------------------
Last Update Date | 09/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 501 E FRANK PHILLIPS BLVD STE 202
-----------------------------------------------------
City | BARTLESVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-336-5454
-----------------------------------------------------
Fax | 918-336-4449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 501 E FRANK PHILLIPS BLVD STE 202
-----------------------------------------------------
City | BARTLESVILLE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74003
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-336-5454
-----------------------------------------------------
Fax | 918-336-4449
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | PENNY J STAMBECK
-----------------------------------------------------
Credential | MBA
-----------------------------------------------------
Telephone | 918-336-5454
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | OK-2149
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------