Basic Information
| Provider Information | |||||||||
| NPI: | 1457519845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WARREN CLINIC KELLY PEDIATRICS SOONERCARE GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6565 S YALE AVE | ||||||||
| Address2: | STE 704 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741368327 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6600 S YALE AVE | ||||||||
| Address2: | STE 1400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2008 | ||||||||
| LastUpdateDate: | 06/02/2008 | ||||||||
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| AuthorizedOfficialLastName: | MASON | ||||||||
| AuthorizedOfficialFirstName: | KATHY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9184886687 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WARREN CLINIC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100739490V | 05 | OK | MEDICAID |