Provider Demographics
NPI:1447551122
Name:WILLIAM R GRUBB MD INC
Entity type:Organization
Organization Name:WILLIAM R GRUBB MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:GRUBB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-756-7110
Mailing Address - Street 1:1705 E 19TH ST
Mailing Address - Street 2:400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-5405
Mailing Address - Country:US
Mailing Address - Phone:918-742-7331
Mailing Address - Fax:918-742-7332
Practice Address - Street 1:1705 E 19TH ST
Practice Address - Street 2:400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-5405
Practice Address - Country:US
Practice Address - Phone:918-742-7331
Practice Address - Fax:918-742-7332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-11
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK10720207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100100630AMedicaid
OK100100630AMedicaid