Provider Demographics
NPI:1942067814
Name:OOLOGAH PEDIATRIC CARE PLLC
Entity type:Organization
Organization Name:OOLOGAH PEDIATRIC CARE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AL
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-915-4211
Mailing Address - Street 1:4458 SPRUCE ST
Mailing Address - Street 2:
Mailing Address - City:KIEFER
Mailing Address - State:OK
Mailing Address - Zip Code:74041-3029
Mailing Address - Country:US
Mailing Address - Phone:918-519-7315
Mailing Address - Fax:
Practice Address - Street 1:115 W. ATLAS AVE
Practice Address - Street 2:
Practice Address - City:OOLOGAH
Practice Address - State:OK
Practice Address - Zip Code:74053-3029
Practice Address - Country:US
Practice Address - Phone:469-915-4211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-06
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty