=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972628352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AHS OKLAHOMA PHYSICIAN GROUP, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/21/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 562 S ELLIOTT ST
-----------------------------------------------------
City | PRYOR
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74361-6411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-825-3389
-----------------------------------------------------
Fax | 918-825-5505
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 562 S ELLIOTT ST
-----------------------------------------------------
City | PRYOR
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74361-6411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-825-3389
-----------------------------------------------------
Fax | 918-825-5505
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | DR. PAUL E. BATTLES
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 918-825-3389
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QA0000X
-----------------------------------------------------
Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 2080
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------