Basic Information
| Provider Information | |||||||||
| NPI: | 1790880391 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ADVANCED HEALTH SYSTEMS OF AMERICA, PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3805 W GORE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805811994 | ||||||||
| FaxNumber: | 5805811285 | ||||||||
| Practice Location | |||||||||
| Address1: | 3805 W GORE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805811994 | ||||||||
| FaxNumber: | 5805811285 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 08/28/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | NDEKWE | ||||||||
| AuthorizedOfficialFirstName: | HENRY-NORBERT | ||||||||
| AuthorizedOfficialMiddleName: | O. | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5805811994 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 21147 OK | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 100748650A | 05 | OK | MEDICAID |