NPIMap

Organization Active NPI

Provectus Diagnostics LLC

  • Clinical Medical Laboratory
  • Tulsa, OK
National Provider Identifier
1104213156
Registry record updated Oct 29, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinical Medical LaboratoryTaxonomy code 291U00000X
Legal business name
PROVECTUS DIAGNOSTICS LLC
Practice address
4150 S 100TH East Ave
Suite 105
Tulsa, OK 74146-3650
Phone
(918) 949-4526
Fax
(918) 949-4549
NPI assigned
Apr 16, 2015
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 29, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Steven T McCormackNPI 1023000338
Title
Owner/Ceo
Phone
(626) 244-8200

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinical Medical Laboratory 291U00000X OK Primary

Addresses

Primary practice location

4150 S 100TH East Ave
Suite 105
Tulsa, OK 74146-3650

Mailing address

4150 S 100TH East Ave
Suite 105
Tulsa, OK 74146-3650
Phone (918) 949-4526

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20141203002266 OK Part B Supplier - Clinic/Group Practice 8628390515 Receives reassigned benefits from 18 practitioners
1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tulsa, OK

Other NPIs on the same Medicare enrollment 1

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory
Tax ID family
Precision Pain Management LLC2 organizations share this tax ID, including this one

Other organizations with this tax ID 1

Organizations that report the same tax identification number in the National Provider Directory.

Locations

4150 S 100th East Ave
Ste 105
Tulsa, OK 74146
Phone (918) 359-5838

Practitioners & affiliated clinicians

Practitioners 15

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 15

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1429142400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1730160000000",
    "number": "1104213156",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4150 S 100TH EAST AVE",
            "address_2": "SUITE 105",
            "city": "TULSA",
            "state": "OK",
            "postal_code": "741463650",
            "telephone_number": "918-949-4526",
            "fax_number": "918-949-4549"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4150 S 100TH EAST AVE",
            "address_2": "SUITE 105",
            "city": "TULSA",
            "state": "OK",
            "postal_code": "741463650",
            "telephone_number": "918-949-4526",
            "fax_number": "918-949-4549"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PROVECTUS DIAGNOSTICS LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2015-04-16",
        "last_updated": "2024-10-29",
        "certification_date": "2024-10-29",
        "status": "A",
        "authorized_official_last_name": "MCCORMACK",
        "authorized_official_first_name": "STEVEN",
        "authorized_official_middle_name": "T",
        "authorized_official_title_or_position": "OWNER/CEO",
        "authorized_official_telephone_number": "626-244-8200"
    },
    "taxonomies": [
        {
            "code": "291U00000X",
            "taxonomy_group": "",
            "desc": "Clinical Medical Laboratory",
            "state": "OK",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Tulsa, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.