Basic Information
| Provider Information | |||||||||
| NPI: | 1720165830 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF OWASSO PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4500 S GARNETT RD | ||||||||
| Address2: | STE 300 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741465229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186649892 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Practice Location | |||||||||
| Address1: | 10502 N 110TH EAST AVE | ||||||||
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| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740556655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183768000 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 03/12/2010 | ||||||||
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| AuthorizedOfficialLastName: | WARLICK | ||||||||
| AuthorizedOfficialFirstName: | JESSICA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9186649892 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200100660A | 05 | OK | MEDICAID |