Basic Information
| Provider Information | |||||||||
| NPI: | 1194396721 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA CANCER SPECIALISTS AND RESEARCH INSTITUTE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12697 E 51ST ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741466236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184992141 | ||||||||
| FaxNumber: | 9184992141 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 E 19TH ST FL 5 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185053200 | ||||||||
| FaxNumber: | 9185053225 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2021 | ||||||||
| LastUpdateDate: | 07/06/2021 | ||||||||
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| AuthorizedOfficialLastName: | DREESEN | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | MGD CARE & CRED COOR | ||||||||
| AuthorizedOfficialTelephone: | 9184992141 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 07/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086X0206X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology |
ID Information
| ID | Type | State | Issuer | Description | 200627090A | 05 | OK | MEDICAID |