=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659645166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ONCOLOGY CONSULTANTS OF NORTHWEST OKLAHOMA P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2012
-----------------------------------------------------
Last Update Date | 03/01/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 600 S MONROE ST RAD ONC DEPT.
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73701-7211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-548-1131
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 5096
-----------------------------------------------------
City | ENID
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73702-5096
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-233-3843
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. PAUL S ERBA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 580-233-3843
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0001X
-----------------------------------------------------
Taxonomy Name | Radiation Oncology Physician
-----------------------------------------------------
License Number | 16411
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------