Basic Information
| Provider Information | |||||||||
| NPI: | 1588266753 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMMEDIATE CARE OF OKLAHOMA, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720790 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704614 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056006869 | ||||||||
| FaxNumber: | 4056006978 | ||||||||
| Practice Location | |||||||||
| Address1: | 502 NORTH BROADWAY | ||||||||
| Address2: | |||||||||
| City: | TECUMSEH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74873 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056006869 | ||||||||
| FaxNumber: | 4056006978 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2020 | ||||||||
| LastUpdateDate: | 11/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | PENWELL | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/COM | ||||||||
| AuthorizedOfficialTelephone: | 4056006869 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
| NPICertificationDate: | 11/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 200459760 | 05 | OK | MEDICAID |