Provider Demographics
NPI:1750518601
Name:DEACONESS PHYSICIAN SERVICES LLC
Entity type:Organization
Organization Name:DEACONESS PHYSICIAN SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PEOPLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:8778929813615-465-7585
Mailing Address - Street 1:5401 N PORTLAND AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2121
Mailing Address - Country:US
Mailing Address - Phone:405-943-6200
Mailing Address - Fax:405-943-0080
Practice Address - Street 1:5401 N PORTLAND AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2121
Practice Address - Country:US
Practice Address - Phone:405-943-6200
Practice Address - Fax:405-943-0080
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-18
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK6254850001Medicare NSC