NPIMap

Organization Active NPI

Green Country Infectious Disease PC

  • Infectious Disease Physician
  • Broken Arrow, OK
National Provider Identifier
1639639321
Registry record updated Apr 3, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Infectious Disease PhysicianTaxonomy code 207RI0200X
Legal business name
GREEN COUNTRY INFECTIOUS DISEASE PC
Practice address
421 Stone Wood Dr
Broken Arrow, OK 74012-1026
Phone
(918) 872-8822
NPI assigned
Mar 20, 2019
Last updated
Apr 3, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 3, 2019

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

Authorized official

Name
Janice L Bracken
Title
Credentialing
Phone
(918) 448-6160

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Infectious Disease PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207RI0200X Primary

Addresses

Primary practice location

421 Stone Wood Dr
Broken Arrow, OK 74012-1026

Mailing address

5908 S 298TH East Ave
Broken Arrow, OK 74014-8405
Phone (918) 872-8822

Other practice location 1

5908 S 298th East Ave
Broken Arrow, OK 74014-8405
Phone (918) 872-8822

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20211110002718 OK Part B Supplier - Clinic/Group Practice 2062801145 Receives reassigned benefits from 4 practitioners
Practice locations: Broken Arrow, OK

National Provider Directory

National Provider Directory

Locations

421 Stone Wood Dr
Broken Arrow, OK 74012
Phone (918) 872-8822

Practitioners & affiliated clinicians

Practitioners 39

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

View all 39

NPI Registry JSON

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

{
    "created_epoch": "1553040000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1554249600000",
    "number": "1639639321",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5908 S 298TH EAST AVE",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740148405",
            "telephone_number": "918-872-8822",
            "fax_number": "918-872-8823"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "421 STONE WOOD DR",
            "city": "BROKEN ARROW",
            "state": "OK",
            "postal_code": "740121026",
            "telephone_number": "918-872-8822"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "5908 S 298th East Ave",
            "address_purpose": "LOCATION",
            "city": "Broken Arrow",
            "state": "OK",
            "postal_code": "740148405",
            "country_code": "US",
            "telephone_number": "918-872-8822",
            "fax_number": "918-872-8823",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "GREEN COUNTRY INFECTIOUS DISEASE PC",
        "organizational_subpart": "NO",
        "enumeration_date": "2019-03-20",
        "last_updated": "2019-04-03",
        "status": "A",
        "authorized_official_last_name": "BRACKEN",
        "authorized_official_first_name": "JANICE",
        "authorized_official_middle_name": "L",
        "authorized_official_title_or_position": "CREDENTIALING",
        "authorized_official_telephone_number": "918-448-6160"
    },
    "taxonomies": [
        {
            "code": "207RI0200X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Internal Medicine, Infectious Disease",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Broken Arrow, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 3, 2019; 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.