Provider Demographics
NPI:1316952112
Name:PIC BARTLESVILLE, PLLC
Entity type:Organization
Organization Name:PIC BARTLESVILLE, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR / BILLING SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLOSA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-713-2621
Mailing Address - Street 1:PO BOX 1207
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53201-1207
Mailing Address - Country:US
Mailing Address - Phone:815-713-2600
Mailing Address - Fax:815-654-8020
Practice Address - Street 1:2334 SE WASHINGTON BLVD STE B&D
Practice Address - Street 2:PIC BARTLESVILLE PLLC
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-7256
Practice Address - Country:US
Practice Address - Phone:918-331-9184
Practice Address - Fax:918-331-9187
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PIC BARTLESVILLE, PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-30
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16429207Q00000X
OK18176261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200117320AMedicaid
OK200117320AMedicaid
OK5883430001Medicare NSC