Provider Demographics
NPI:1164479648
Name:AEGIS ENTERPRISES
Entity type:Organization
Organization Name:AEGIS ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR/OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GOODMAN
Authorized Official - Suffix:II
Authorized Official - Credentials:RN
Authorized Official - Phone:918-392-0555
Mailing Address - Street 1:10404 E 55TH PL
Mailing Address - Street 2:SUITE W
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-6500
Mailing Address - Country:US
Mailing Address - Phone:918-392-0555
Mailing Address - Fax:918-392-0556
Practice Address - Street 1:10404 E 55TH PL
Practice Address - Street 2:SUITE W
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6500
Practice Address - Country:US
Practice Address - Phone:918-392-0555
Practice Address - Fax:918-392-0556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200078770AMedicaid
OK5683510001Medicare NSC