# GREEN COUNTRY INFECTIOUS DISEASE PC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1639639321
- **Authorized official:** JANICE L BRACKEN (CREDENTIALING)
- **Authorized official phone:** (918) 448-6160

## Contact information

- **Practice address:** 421 STONE WOOD DR, BROKEN ARROW, OK 74012-1026
- **Practice address phone:** (918) 872-8822
- **Mailing address:** 5908 S 298TH EAST AVE, BROKEN ARROW, OK 74014-8405
- **Mailing address phone:** (918) 872-8822
- **Mailing address fax:** (918) 872-8823

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207RI0200X | Infectious Disease Physician | — | NULL | Yes |
| 207RI0200X | Infectious Disease Physician | — | — | Yes |

## Other

- **Enumeration date:** 03/20/2019
- **Last updated:** 04/03/2019