MEDICARE: DEACONESS PHYSICIAN SERVICES 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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1750518601
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEACONESS PHYSICIAN SERVICES LLC

Provider Business Mailing Address
First Line	:	5401 N PORTLAND AVE
Second Line	:	SUITE 410
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2121
Country	:	US
Telephone Number	:	405-943-6200
Fax Number	:	405-943-0080

Provider Business Practice Location Address
First Line	:	5401 N PORTLAND AVE
Second Line	:	SUITE 410
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-2121
Country	:	US
Telephone Number	:	405-943-6200
Fax Number	:	405-943-0080

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	BRIAN A PEOPLES
Credential	:
Telephone Number	:	87789298136154657585

Provider Enumeration Date	:	06/18/2009
Last Update Date	:	01/17/2013

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