Healthcare Provider Details

I. General information

NPI: 1235050089
Provider Name (Legal Business Name): GENESIS MEDICAL PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2026
Last Update Date: 07/24/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 CRADDUCK RD
ADA OK
74820
US

IV. Provider business mailing address

1100 CRADDUCK RD
ADA OK
74820
US

V. Phone/Fax

Practice location:
  • Phone: 580-221-2022
  • Fax: 580-221-2024
Mailing address:
  • Phone: 580-221-2022
  • Fax: 580-221-2024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State

VIII. Authorized Official

Name: SHERRY LYNNE CLARK
Title or Position: BILLING/CREDENTIALING
Credential:
Phone: 580-223-5180