Basic Information
| Provider Information | |||||||||
| NPI: | 1699704270 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROFESSIONAL CORPORATION OF PSYCHIATRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5100 N BROOKLINE AVE | ||||||||
| Address2: | 900 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731123623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056043170 | ||||||||
| FaxNumber: | 4056043163 | ||||||||
| Practice Location | |||||||||
| Address1: | 5100 N BROOKLINE AVE | ||||||||
| Address2: | 900 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731123623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056043170 | ||||||||
| FaxNumber: | 4056043163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | ANDRUS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4056043170 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 1041C0700X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 2084P0800X | X | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.