Basic Information
Provider Information
NPI: 1508891789
EntityType: 2
ReplacementNPI:  
OrganizationName: CARDIOLOGY SERVICES OF ENID
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Mailing Information
Address1: DEPT 960278
Address2:  
City: OKLAHOMA CITY
State: OK
PostalCode: 731960278
CountryCode: US
TelephoneNumber: 5805481367
FaxNumber: 5805481583
Practice Location
Address1: 707 S MONROE ST
Address2:  
City: ENID
State: OK
PostalCode: 737017286
CountryCode: US
TelephoneNumber: 5806167630
FaxNumber: 5802377516
Other Information
ProviderEnumerationDate: 07/12/2006
LastUpdateDate: 02/25/2011
NPIDeactivationReasonCode:  
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AuthorizedOfficialLastName: BROWN
AuthorizedOfficialFirstName: JEFF
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: VP RURAL PHYSICIAN PRACT MGMT
AuthorizedOfficialTelephone: 5805481367
IsSoleProprietor:  
IsOrganizationSubpart: N
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Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207RC0000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease

ID Information
IDTypeStateIssuerDescription
200106320A05OK MEDICAID
200608360A05KS MEDICAID


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