Basic Information
| Provider Information | |||||||||
| NPI: | 1134296577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORD | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | G. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6600 S YALE AVE | ||||||||
| Address2: | SUITE 1200 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741363347 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184886687 | ||||||||
| FaxNumber: | 9184886098 | ||||||||
| Practice Location | |||||||||
| Address1: | 6151 S YALE AVE | ||||||||
| Address2: | SUITE 1305 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184949450 | ||||||||
| FaxNumber: | 9184949437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 07/27/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 117899 | MO | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0120X | 117899 | MO | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 2086S0120X | 28432 | OK | Y | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200335580A | 05 | OK | MEDICAID | 2038833400 | 05 | MO | MEDICAID |