Provider Demographics
NPI:1053431452
Name:FAMILY CARE OF BROKEN ARROW, INC.
Entity type:Organization
Organization Name:FAMILY CARE OF BROKEN ARROW, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR D.O.
Authorized Official - Prefix:DR
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:O
Authorized Official - Last Name:JESKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-455-7777
Mailing Address - Street 1:3100 S. ELM PL.
Mailing Address - Street 2:SUITE A
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-7910
Mailing Address - Country:US
Mailing Address - Phone:918-455-7777
Mailing Address - Fax:918-455-8105
Practice Address - Street 1:3100 S. ELM PL.
Practice Address - Street 2:SUITE A
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-7910
Practice Address - Country:US
Practice Address - Phone:918-455-7777
Practice Address - Fax:918-455-8105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0749960001OtherPTAN/DMERC
OKCS2603OtherRAILROAD MEDICARE
OK0749960001OtherPTAN/DMERC