MEDICARE: TRIAD HEALTH SYSTEMS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1245867258
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TRIAD HEALTH SYSTEMS LLC

Provider Business Mailing Address
First Line	:	2703 N 14TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601
Country	:	US
Telephone Number	:	580-765-9451
Fax Number	:

Provider Business Practice Location Address
First Line	:	2703 N 14TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601
Country	:	US
Telephone Number	:	580-765-9451
Fax Number	:

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	AMY BEVERLEY
Credential	:
Telephone Number	:	580-765-9451

Provider Enumeration Date	:	03/27/2020
Last Update Date	:	06/08/2020

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