Basic Information
| Provider Information | |||||||||
| NPI: | 1144279068 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WATERVIEW MEDICAL CENTRE | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1330 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730701330 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056924777 | ||||||||
| FaxNumber: | 4056924778 | ||||||||
| Practice Location | |||||||||
| Address1: | 2625 SW 119TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731702654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056924777 | ||||||||
| FaxNumber: | 4056924778 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2006 | ||||||||
| LastUpdateDate: | 08/31/2012 | ||||||||
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| AuthorizedOfficialLastName: | TERRELL | ||||||||
| AuthorizedOfficialFirstName: | GREG | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP, COO | ||||||||
| AuthorizedOfficialTelephone: | 4053071000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100700690N | 05 | OK | MEDICAID |