Basic Information
Provider Information | |||||||||
NPI: | 1548473184 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEPHROLOGY AND HYPERTENSION CLINIC, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1380 S DOUGLAS BLVD | ||||||||
Address2: |   | ||||||||
City: | MIDWEST CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731305215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057370881 | ||||||||
FaxNumber: | 4057370899 | ||||||||
Practice Location | |||||||||
Address1: | 1380 S DOUGLAS BLVD | ||||||||
Address2: |   | ||||||||
City: | MIDWEST CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731305215 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4057370881 | ||||||||
FaxNumber: | 4057370899 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MCENTIRE | ||||||||
AuthorizedOfficialFirstName: | S | ||||||||
AuthorizedOfficialMiddleName: | W | ||||||||
AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
AuthorizedOfficialTelephone: | 4057370881 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
ID | Type | State | Issuer | Description | 731570351-001 | 01 | OK | BCBS DR N ID | OTHER |