Basic Information
| Provider Information | |||||||||
| NPI: | 1972698553 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF TULSA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 S UTICA AVE STE 365 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741044004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187283354 | ||||||||
| FaxNumber: | 9187287554 | ||||||||
| Practice Location | |||||||||
| Address1: | 1120 S UTICA AVE | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185791000 | ||||||||
| FaxNumber: | 9186642521 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 06/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | DIXON | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 9187283354 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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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 | 200094670A | 05 | OK | MEDICAID |