| Parkside Professional | |
|
1620 E 12th St Tulsa OK 74120-5407 | |
| (918) 588-8874 | |
| Not Available |
| Full Name | Parkside Professional |
|---|---|
| Speciality | Clinic/Center |
| Location | 1620 E 12th St, Tulsa, Oklahoma |
| Authorized Official Name and Position | Saunya D. Moore (CFO) |
| Authorized Official Contact | 9185888874 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Parkside Professional 1620 E 12th St Tulsa OK 74120-5407 Ph: (918) 588-8874 | Parkside Professional 1620 E 12th St Tulsa OK 74120-5407 Ph: (918) 588-8874 |
| NPI Number | 1356552111 |
|---|---|
| Provider Enumeration Date | 05/24/2007 |
| Last Update Date | 10/31/2012 |
| Medicare PECOS PAC ID | 5496644049 |
|---|---|
| Medicare Enrollment ID | O20040312000336 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1356552111 | NPI | - | NPPES |
| 100738360D | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0850X | Clinic/center - Adult Mental Health | 2261 (Oklahoma) | Primary |
| 261QM0855X | Clinic/center - Adolescent And Children Mental Health | 2261 (Oklahoma) | Secondary |
| Provider Name | Peteryne D Miller |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1720026362 PECOS PAC ID: 9537172556 Enrollment ID: I20060721000058 |
| Provider Name | John B White |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1063453223 PECOS PAC ID: 8325148034 Enrollment ID: I20070711000102 |
| Provider Name | Anton Surja |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1437296001 PECOS PAC ID: 0749373496 Enrollment ID: I20070911000528 |
| Provider Name | Dion Owens |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1336251990 PECOS PAC ID: 9931133519 Enrollment ID: I20080422000632 |
| Provider Name | Daphnie L Peak |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1780054403 PECOS PAC ID: 5597068395 Enrollment ID: I20160128002112 |
| Provider Name | Stephanie S Mcquarters |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598284358 PECOS PAC ID: 0345294955 Enrollment ID: I20180116000408 |
| Provider Name | William J List |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1639448079 PECOS PAC ID: 1355602368 Enrollment ID: I20180307000827 |
| Provider Name | Jacqueline Gilmore |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1972955748 PECOS PAC ID: 6507116043 Enrollment ID: I20180905000526 |
| Provider Name | Audrey K Bryan |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1235319864 PECOS PAC ID: 0042563025 Enrollment ID: I20181020000151 |
| Provider Name | Gail M Flack |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1396980728 PECOS PAC ID: 0941547244 Enrollment ID: I20190124001789 |
| Provider Name | James D Pollard |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1982161568 PECOS PAC ID: 7719228097 Enrollment ID: I20190415001944 |
| Provider Name | Deborah S Harrington |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1194386029 PECOS PAC ID: 5294161923 Enrollment ID: I20200128002910 |
| Provider Name | Zachary J Sullivan |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1568880094 PECOS PAC ID: 7416204987 Enrollment ID: I20220805000420 |
| Provider Name | Matthew Sharp |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1790224293 PECOS PAC ID: 8729464425 Enrollment ID: I20230815001242 |
| Provider Name | Michelle Sharp |
|---|---|
| Provider Type | Practitioner - Psychiatry |
| Provider Identifiers | NPI Number: 1710489869 PECOS PAC ID: 2264817642 Enrollment ID: I20240311000566 |
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