Basic Information
Provider Information | |||||||||
NPI: | 1235293846 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | AHS OKLAHOMA PHYSICIAN GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | W. EDWARD CLYMER, DO PAWNEE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1145 S UTICA AVE | ||||||||
Address2: | SUITE 110 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741044000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185793825 | ||||||||
FaxNumber: | 9185791262 | ||||||||
Practice Location | |||||||||
Address1: | 300 BOULDER ST | ||||||||
Address2: |   | ||||||||
City: | PAWNEE | ||||||||
State: | OK | ||||||||
PostalCode: | 740583801 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9187622522 | ||||||||
FaxNumber: | 9187623510 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/20/2006 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LANGLAND | ||||||||
AuthorizedOfficialFirstName: | ROBERT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 9185791000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.