Basic Information
Provider Information | |||||||||
NPI: | 1578714721 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HEARTLAND PATHOLOGY CONSULTANTS, PCS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 26343 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731260343 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057050018 | ||||||||
FaxNumber: | 4057050029 | ||||||||
Practice Location | |||||||||
Address1: | 3509 FRENCH PARK DR | ||||||||
Address2: | SUITE D | ||||||||
City: | EDMOND | ||||||||
State: | OK | ||||||||
PostalCode: | 730347296 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057050018 | ||||||||
FaxNumber: | 4057050029 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/07/2008 | ||||||||
LastUpdateDate: | 10/07/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHEADLE | ||||||||
AuthorizedOfficialFirstName: | ROSIE | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | BILLING SUPERVISOR | ||||||||
AuthorizedOfficialTelephone: | 4057050018 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | HEARTLAND PATHOLOGY CONSULTANTS, PC | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 16447 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice |   |
ID Information
ID | Type | State | Issuer | Description | 100746640A | 05 | OK |   | MEDICAID |