Provider Demographics
NPI:1972698553
Name:GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF TULSA PLLC
Entity type:Organization
Organization Name:GREEN COUNTRY EMERGENCY PHYSICIANS GROUP OF TULSA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:DIXON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-728-3354
Mailing Address - Street 1:1145 S UTICA AVE STE 365
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4004
Mailing Address - Country:US
Mailing Address - Phone:918-728-3354
Mailing Address - Fax:918-728-7554
Practice Address - Street 1:1120 S UTICA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104
Practice Address - Country:US
Practice Address - Phone:918-579-1000
Practice Address - Fax:918-664-2521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200094670AMedicaid
OK200094670AMedicaid
OKDF3797Medicare PIN