Basic Information
| Provider Information | |||||||||
| NPI: | 1598962771 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DR.MICKEY TYRRELL, M.D. PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HORNET HEALTHCARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 803 N FOREMAN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743011412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182562261 | ||||||||
| FaxNumber: | 9182562304 | ||||||||
| Practice Location | |||||||||
| Address1: | 803 N FOREMAN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | VINITA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743011412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182562261 | ||||||||
| FaxNumber: | 9182562304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2007 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | TYRRELL | ||||||||
| AuthorizedOfficialFirstName: | MICKEY | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9182562261 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22897 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200067580A | 05 | OK | MEDICAID |