=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205052149
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERN OKLAHOMA EAR, NOSE & THROAT INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/18/2007
-----------------------------------------------------
Last Update Date | 12/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5020 E 68TH ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-492-3636
-----------------------------------------------------
Fax | 918-494-8915
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5020 E 68TH ST
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-3307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-492-3636
-----------------------------------------------------
Fax | 918-494-8915
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING CLERK
-----------------------------------------------------
Name | SUSAN WEATHERLY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-491-3314
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YS0012X
-----------------------------------------------------
Taxonomy Name | Sleep Medicine (Otolaryngology) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------