Basic Information
| Provider Information | |||||||||
| NPI: | 1437125218 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TICHENOR | ||||||||
| FirstName: | GREGORY | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | TICHENOR | ||||||||
| OtherFirstName: | GREG | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | P O BOX 960046 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731960001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8774854474 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1600 HOSPITAL PKWY | ||||||||
| Address2: | |||||||||
| City: | BEDFORD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760226913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178484000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 12/31/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | J9391 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930047705 | 01 | TX | RAILROAD MCARE THRU HEB | OTHER | 132071503 | 05 | TX | MEDICAID | 85V309 | 01 | TX | BCBS THRU HEB | OTHER |