Basic Information
| Provider Information | |||||||||
| NPI: | 1316952112 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PIC BARTLESVILLE, PLLC | ||||||||
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| OtherOrganizationName: | PIC BARTLESVILLE, PLLC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1207 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532011207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157132600 | ||||||||
| FaxNumber: | 8156548020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2334 SE WASHINGTON BLVD STE B&D | ||||||||
| Address2: | PIC BARTLESVILLE PLLC | ||||||||
| City: | BARTLESVILLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740067256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183319184 | ||||||||
| FaxNumber: | 9183319187 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2006 | ||||||||
| LastUpdateDate: | 02/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | KLOSA | ||||||||
| AuthorizedOfficialFirstName: | MONICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR / BILLING SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 8157132621 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PIC BARTLESVILLE, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16429 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QU0200X | 18176 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 200117320A | 05 | OK | MEDICAID |