MEDICARE: PRIMARY CARE CENTERS OF AMERICA, 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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1659855666	OTHER	OK	NPI

General Provider Information

NPI Number	:	1659855666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRIMARY CARE CENTERS OF AMERICA, LLC

Provider Business Mailing Address
First Line	:	800 W 18TH ST STE 130
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73013-3759
Country	:	US
Telephone Number	:	405-513-7257
Fax Number	:	405-513-7267

Provider Business Practice Location Address
First Line	:	800 W 18TH ST STE 130
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73013-3759
Country	:	US
Telephone Number	:	405-513-7257
Fax Number	:	405-513-7267

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DESIREE A KOENIG
Credential	:
Telephone Number	:	405-513-6334

Provider Enumeration Date	:	09/17/2018
Last Update Date	:	01/16/2019

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