Basic Information
| Provider Information | |||||||||
| NPI: | 1194733360 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARY'S PEAK EMERGENCY PHYSICIANS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 96353 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731436353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009623303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3600 NW SAMARITAN DR | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973303737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417685021 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2006 | ||||||||
| LastUpdateDate: | 11/15/2017 | ||||||||
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| AuthorizedOfficialLastName: | GOWING | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5417685021 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 078548 | 05 | OR | MEDICAID |