Basic Information
| Provider Information | |||||||||
| NPI: | 1003288978 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ERNEST MCKENZIE MD PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N 30TH ST | ||||||||
| Address2: | N | ||||||||
| City: | CLINTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736013117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803235363 | ||||||||
| FaxNumber: | 5803311406 | ||||||||
| Practice Location | |||||||||
| Address1: | 4625 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731093831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803232363 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2015 | ||||||||
| LastUpdateDate: | 10/30/2015 | ||||||||
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| AuthorizedOfficialLastName: | MCKENZIE | ||||||||
| AuthorizedOfficialFirstName: | ERNEST | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5807725551 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
No ID Information.