Basic Information
| Provider Information | |||||||||
| NPI: | 1679532170 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OLIVE | ||||||||
| FirstName: | SUZANNE | ||||||||
| MiddleName: | RENEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1515 N HARVARD AVE | ||||||||
| Address2: | STE E | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741154957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188326049 | ||||||||
| FaxNumber: | 9188326055 | ||||||||
| Practice Location | |||||||||
| Address1: | 1725 E 19TH ST | ||||||||
| Address2: | STE 200 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741045415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187488381 | ||||||||
| FaxNumber: | 9187488397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2006 | ||||||||
| LastUpdateDate: | 11/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207KA0200X | 16883 | OK | N | Allopathic & Osteopathic Physicians | Allergy & Immunology | Allergy | 207RC0200X | 16883 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine | 207RP1001X | 16883 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207RS0012X | 16883 | OK | N | Allopathic & Osteopathic Physicians | Internal Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | H90060663001 | 01 | BLUE CROSS BLUE SHIELD | OTHER |