Provider Demographics
NPI:1942298385
Name:ADVANCED FAMILY THERAPEUTIC
Entity type:Organization
Organization Name:ADVANCED FAMILY THERAPEUTIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CO OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHADID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-579-5858
Mailing Address - Street 1:3280 MARSHALL AVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73072-8028
Mailing Address - Country:US
Mailing Address - Phone:405-579-5858
Mailing Address - Fax:405-292-1787
Practice Address - Street 1:3280 MARSHALL AVE
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072
Practice Address - Country:US
Practice Address - Phone:405-579-5858
Practice Address - Fax:405-292-1787
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2008-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200019720AMedicaid