Basic Information
| Provider Information | |||||||||
| NPI: | 1730560699 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PREMIER PEDIATRIC AND ADOLESCENT CARE | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 2009 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188164024 | ||||||||
| FaxNumber: | 9188164025 | ||||||||
| Practice Location | |||||||||
| Address1: | 2009 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188164024 | ||||||||
| FaxNumber: | 9188164025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2015 | ||||||||
| LastUpdateDate: | 06/16/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOOS | ||||||||
| AuthorizedOfficialFirstName: | TRACY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9188164024 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.