Healthcare Provider Details

I. General information

NPI: 1255344206
Provider Name (Legal Business Name): SOUTHWESTERN EMERGENCY DEPARTMENT PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5602 SW LEE BLVD
LAWTON OK
73505-9635
US

IV. Provider business mailing address

4401 W MEMORIAL RD SUITE 121
OKLAHOMA CITY OK
73134-1785
US

V. Phone/Fax

Practice location:
  • Phone: 580-531-4700
  • Fax: 580-531-4889
Mailing address:
  • Phone: 405-751-4664
  • Fax: 405-749-4561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2231
License Number StateOK

VIII. Authorized Official

Name: MR. GEORGE KRUGER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 580-531-4701