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NPI Code Detail

MEDICARE: SHAWNEE MEDICAL CENTER CLINIC, INC

MEDICARE: SHAWNEE MEDICAL CENTER CLINIC, INC
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
1207LP2900XPain Medicine (Anesthesiology) Physician
2207Q00000XFamily Medicine Physician
3207R00000XInternal Medicine Physician
4207RG0100XGastroenterology Physician
5207RP1001XPulmonary Disease Physician
6207RR0500XRheumatology Physician
7207RC0000XCardiovascular Disease Physician

General Provider Information

NPI Number : 1841832755
Entity Type Code : Organization
Provider Name (Legal Business Name) : SHAWNEE MEDICAL CENTER CLINIC, INC
Provider Business Mailing Address
First Line : 3012 ARLINGTON ST
Second Line :
City : ADA
State : OK
Zip : 74820-3073
Country : US
Telephone Number : 580-272-0715
Fax Number : 580-272-0772
Provider Business Practice Location Address
First Line : 3012 ARLINGTON ST
Second Line :
City : ADA
State : OK
Zip : 74820-3073
Country : US
Telephone Number : 580-272-0715
Fax Number : 580-272-0772
Authorized Official
Title or Position : PROVIDER ENROLLMENT/INS CREDENTIAL
Name : CRYSTAL L PENA
Credential :
Telephone Number : 405-272-7452
Provider Enumeration Date : 10/11/2019
Last Update Date : 10/11/2019

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Directions to “SHAWNEE MEDICAL CENTER CLINIC, INC ” Practice Location

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