Basic Information
| Provider Information | |||||||||
| NPI: | 1154753614 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IMMEDIATE CARE OF OKLAHOMA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8001 S I 35 SERVICE RD | ||||||||
| Address2: | SUITE 106 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731492906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056006869 | ||||||||
| FaxNumber: | 4056006978 | ||||||||
| Practice Location | |||||||||
| Address1: | 805 W COVELL RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730032176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052165373 | ||||||||
| FaxNumber: | 4052165017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2013 | ||||||||
| LastUpdateDate: | 08/07/2013 | ||||||||
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| AuthorizedOfficialLastName: | PENWELL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | COM/MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4056006869 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 3873 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.