Healthcare Provider Details

I. General information

NPI: 1457540015
Provider Name (Legal Business Name): SAINT MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2007
Last Update Date: 03/22/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18961 NE 23RD STREET
HARRAH OK
73045
US

IV. Provider business mailing address

18961 NE 23RD STREET
HARRAH OK
73045
US

V. Phone/Fax

Practice location:
  • Phone: 405-772-4650
  • Fax: 405-772-4653
Mailing address:
  • Phone: 405-772-4650
  • Fax: 405-772-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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