MEDICARE: AERIE FAMILY WELLNESS & MEDICAL GROUP PC

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	9483	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1316981004	OTHER	OK	NPI

General Provider Information

NPI Number	:	1184744203
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AERIE FAMILY WELLNESS & MEDICAL GROUP PC

Provider Business Mailing Address
First Line	:	3242 E ADMIRAL PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74110-5536
Country	:	US
Telephone Number	:	918-836-6454
Fax Number	:	918-836-6455

Provider Business Practice Location Address
First Line	:	3242 E ADMIRAL PL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74110-5536
Country	:	US
Telephone Number	:	918-836-6454
Fax Number	:	918-836-6455

Authorized Official
Title or Position	:	SECRETARY
Name	:	DR. VERNON C SMITH
Credential	:	D.C.
Telephone Number	:	918-836-6454

Provider Enumeration Date	:	03/30/2007
Last Update Date	:	08/22/2020

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