Healthcare Provider Details

I. General information

NPI: 1023699956
Provider Name (Legal Business Name): SAINT MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 W 15TH ST
EDMOND OK
73013-3747
US

IV. Provider business mailing address

416 W 15TH ST
EDMOND OK
73013-3747
US

V. Phone/Fax

Practice location:
  • Phone: 405-513-8535
  • Fax:
Mailing address:
  • Phone: 405-513-8535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL L PENA
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 405-272-7452