Provider Demographics
NPI:1720165830
Name:GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF OWASSO PLLC
Entity type:Organization
Organization Name:GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF OWASSO PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WARLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-664-9892
Mailing Address - Street 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 300
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-664-9892
Mailing Address - Fax:918-664-2521
Practice Address - Street 1:10502 N 110TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6655
Practice Address - Country:US
Practice Address - Phone:918-376-8000
Practice Address - Fax:918-664-2521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200100660AMedicaid
OKDF6024Medicare PIN
OK200100660AMedicaid