MEDICARE: WILLIAMS MEDICAL GROUP PRACTICE, LLC

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
2	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1295305035
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAMS MEDICAL GROUP PRACTICE, LLC

Provider Business Mailing Address
First Line	:	701 CEDAR LAKE BLVD STE 120
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-7815
Country	:	US
Telephone Number	:	405-445-1210
Fax Number	:

Provider Business Practice Location Address
First Line	:	1805 1/2 E 17TH AVE
Second Line	:
City	:	HUTCHINSON
State	:	KS
Zip	:	67501-1102
Country	:	US
Telephone Number	:	620-615-7197
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	GRANT ASAY
Credential	:
Telephone Number	:	405-445-1210

Provider Enumeration Date	:	06/24/2021
Last Update Date	:	02/24/2023

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