MEDICARE: CASEY HANNA MD PROFESSIONAL CORPORATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	21947	OK

General Provider Information

NPI Number	:	1003099276
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CASEY HANNA MD PROFESSIONAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 894
Second Line	:
City	:	WAGONER
State	:	OK
Zip	:	74477-0894
Country	:	US
Telephone Number	:	918-485-5188
Fax Number	:	918-485-5402

Provider Business Practice Location Address
First Line	:	1202 W CHEROKEE ST STE E
Second Line	:
City	:	WAGONER
State	:	OK
Zip	:	74467-4629
Country	:	US
Telephone Number	:	918-485-5188
Fax Number	:	915-485-5402

Authorized Official
Title or Position	:	OWNER
Name	:	BRYAN CASEY HANNA
Credential	:	MD
Telephone Number	:	918-485-5188

Provider Enumeration Date	:	12/11/2007
Last Update Date	:	07/22/2009

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