Provider Demographics
NPI:1548505258
Name:EDMOND PEDIATRICS
Entity type:Organization
Organization Name:EDMOND PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:FREDRICK
Authorized Official - Last Name:KROUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-381-8600
Mailing Address - Street 1:2109 N KELLY AVE
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3908
Mailing Address - Country:US
Mailing Address - Phone:405-513-8880
Mailing Address - Fax:405-285-5912
Practice Address - Street 1:2109 N KELLY AVE
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3908
Practice Address - Country:US
Practice Address - Phone:405-513-8880
Practice Address - Fax:405-285-5912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-06
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21244208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100208810AMedicaid