Healthcare Provider Details

I. General information

NPI: 1194403055
Provider Name (Legal Business Name): SAINT MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 07/10/2023
Certification Date: 07/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 WALNUT DR
ARDMORE OK
73401-2354
US

IV. Provider business mailing address

1115 WALNUT DR
ARDMORE OK
73401-2354
US

V. Phone/Fax

Practice location:
  • Phone: 405-231-3737
  • Fax: 405-272-6144
Mailing address:
  • Phone: 405-231-3737
  • Fax: 405-272-6144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL L PENA
Title or Position: PROVIDER ENROLLMENT
Credential:
Phone: 405-272-7452