Healthcare Provider Details

I. General information

NPI: 1285978007
Provider Name (Legal Business Name): MEDICINE WHEEL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/16/2012
Last Update Date: 11/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 BUFFALO STREET
CADDO OK
74729
US

IV. Provider business mailing address

PO BOX 146
CADDO OK
74729-0146
US

V. Phone/Fax

Practice location:
  • Phone: 580-367-2100
  • Fax: 580-367-2103
Mailing address:
  • Phone: 580-367-2100
  • Fax: 580-367-2103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number2982
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2982
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: PAUL E WEATHERS
Title or Position: MEDICAL DIRECTOR
Credential: DO
Phone: 580-367-2100