Healthcare Provider Details

I. General information

NPI: 1396314118
Provider Name (Legal Business Name): WILLIAMS MEDICAL GROUP PRACTICE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2021
Last Update Date: 07/02/2021
Certification Date: 07/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 W 15TH ST
LIBERAL KS
67901-2464
US

IV. Provider business mailing address

701 CEDAR LAKE BLVD STE 120
OKLAHOMA CITY OK
73114-7815
US

V. Phone/Fax

Practice location:
  • Phone: 620-417-9012
  • Fax: 620-417-9013
Mailing address:
  • Phone: 405-445-1210
  • Fax: 405-445-3310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GRANT ASAY
Title or Position: CEO
Credential:
Phone: 405-445-1210