Provider Demographics
NPI:1215975883
Name:TULSA PEDIATRIC AND ADOLESCENT MEDICINE, PC
Entity type:Organization
Organization Name:TULSA PEDIATRIC AND ADOLESCENT MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:K
Authorized Official - Last Name:GIST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-748-7620
Mailing Address - Street 1:1919 S WHEELING AVE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5638
Mailing Address - Country:US
Mailing Address - Phone:918-748-7620
Mailing Address - Fax:918-748-7647
Practice Address - Street 1:1919 S WHEELING AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5638
Practice Address - Country:US
Practice Address - Phone:918-748-7620
Practice Address - Fax:918-748-7647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty