Provider Demographics
NPI:1316105703
Name:WARREN CLINIC MEDICAID GROUP 100739490B
Entity type:Organization
Organization Name:WARREN CLINIC MEDICAID GROUP 100739490B
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHEY
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPLISSEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-488-6687
Mailing Address - Street 1:6600 S YALE AVE
Mailing Address - Street 2:SUITE 1400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6600 S YALE AVE
Practice Address - Street 2:SUITE 1400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-3310
Practice Address - Country:US
Practice Address - Phone:918-488-6001
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WARREN CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-06-02
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100739490BMedicaid