Basic Information
| Provider Information | |||||||||
| NPI: | 1639219108 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GREENWAY | ||||||||
| FirstName: | ROY | ||||||||
| MiddleName: | MACK | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD, FACS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREENWAY | ||||||||
| OtherFirstName: | ROY | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 2339 | ||||||||
| Address2: | |||||||||
| City: | ELK CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 736482339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802252517 | ||||||||
| FaxNumber: | 5802253167 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 SW 80TH ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731398123 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056015169 | ||||||||
| FaxNumber: | 4056019095 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2007 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 23986 | OK | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 208600000X | 23986 | OK | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200196600A | 05 | OK | MEDICAID |