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General NPI Number Information
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NPI Number | 1790155562
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Entity Type | Organization
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Legal Business Name | CALDWELL MEDICAL GROUP OF NORTH TULSA LLC
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Dates
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Enumeration Date | 10/05/2015
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Last Update Date | 11/05/2015
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Provider Practice Location Address
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Address Line | 8014 S 101ST EAST AVE
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City | TULSA
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State | OK
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Zip | 74133-4579
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Country | US
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Telephone | 918-949-9910
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Fax |
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Provider Business Mailing Address
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Address Line | 8014 S 101ST EAST AVE
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City | TULSA
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State | OK
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Zip | 74133-4579
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Country | US
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Telephone | 918-949-9910
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Fax |
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Authorized Official
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Title or Position | SOLE MEMBER
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Name | KAMMIE CALDWELL
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Credential | MD
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Telephone | 918-485-0291
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number |
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License Number State |
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