NPIMap

Organization Active NPI

Prairie Gardens Medical LLC

  • General Practice Physician
  • Oklahoma City, OK
National Provider Identifier
1689280067
Registry record updated Sep 29, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
General Practice PhysicianTaxonomy code 208D00000X
Legal business name
PRAIRIE GARDENS MEDICAL LLC
Practice address
1213 NW 122ND St Ste 401
Oklahoma City, OK 73114-7000
Phone
(405) 962-9123
Fax
(405) 962-8125
NPI assigned
Sep 21, 2020
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Sep 29, 2020

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

Authorized official

Name
Dianne Genene Tupper, RN/OPACNPI 1740578103
Title
Practice Manager
Phone
(405) 742-8898

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
General Practice PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 208D00000X Primary

Addresses

Primary practice location

1213 NW 122ND St Ste 401
Oklahoma City, OK 73114-7000

Mailing address

175 Lary LN
Guthrie, OK 73044-6542
Phone (405) 962-8123

Electronic endpoints 1

TypeEndpointUseAffiliation
Other URL PGMHealth.net

Medicare participation

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

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20201001003324 OK Part B Supplier - Clinic/Group Practice 6305265877 Receives reassigned benefits from 10 practitioners
Practice locations: Oklahoma City, OK

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 12

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

NPI Registry JSON

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

{
    "created_epoch": "1600646400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1601337600000",
    "number": "1689280067",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "175 LARY LN",
            "city": "GUTHRIE",
            "state": "OK",
            "postal_code": "730446542",
            "telephone_number": "405-962-8123",
            "fax_number": "405-962-8125"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1213 NW 122ND ST STE 401",
            "city": "OKLAHOMA CITY",
            "state": "OK",
            "postal_code": "731147000",
            "telephone_number": "405-962-9123",
            "fax_number": "405-962-8125"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PRAIRIE GARDENS MEDICAL LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2020-09-21",
        "last_updated": "2020-09-29",
        "certification_date": "2020-09-29",
        "status": "A",
        "authorized_official_last_name": "TUPPER",
        "authorized_official_first_name": "DIANNE",
        "authorized_official_middle_name": "GENENE",
        "authorized_official_title_or_position": "PRACTICE MANAGER",
        "authorized_official_telephone_number": "405-742-8898",
        "authorized_official_credential": "RN/OPAC"
    },
    "taxonomies": [
        {
            "code": "208D00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "General Practice",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "OTHERS",
            "endpointTypeDescription": "Other URL",
            "endpoint": "PGMHealth.net",
            "affiliation": "N",
            "endpointDescription": "Encrypted website",
            "address_1": "1213 NW 122nd St Ste 401",
            "city": "Oklahoma City",
            "state": "OK",
            "country_code": "US",
            "postal_code": "731147000",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Oklahoma City, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 29, 2020; 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.