Basic Information
| Provider Information | |||||||||
| NPI: | 1659560563 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RT MEDICAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2514 NORTH MERIDIAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731071035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057221110 | ||||||||
| FaxNumber: | 4057218263 | ||||||||
| Practice Location | |||||||||
| Address1: | 2514 NORTH MERIDIAN AVENUE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731071035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057221110 | ||||||||
| FaxNumber: | 4057218263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2007 | ||||||||
| LastUpdateDate: | 05/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | TIPSWORD | ||||||||
| AuthorizedOfficialFirstName: | HEATHER | ||||||||
| AuthorizedOfficialMiddleName: | ROSS | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4057221110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3988 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200032500A | 05 | OK | MEDICAID |