Basic Information
| Provider Information | |||||||||
| NPI: | 1194751495 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CARDIOLOGY DIAGNOSTICS OF TULSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6151 S YALE AVE | ||||||||
| Address2: | #400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184948500 | ||||||||
| FaxNumber: | 9183075578 | ||||||||
| Practice Location | |||||||||
| Address1: | 6151 S YALE AVE | ||||||||
| Address2: | #400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741361907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184948500 | ||||||||
| FaxNumber: | 9183075578 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 09/18/2008 | ||||||||
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| AuthorizedOfficialLastName: | SPAIN | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 9184948500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CARDIOLOGY OF TULSA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 100738900A | 05 | OK | MEDICAID | CS9846 | 01 | OK | RAILROAD MEDICARE | OTHER |