Healthcare Provider Details

I. General information

NPI: 1871539015
Provider Name (Legal Business Name): ROBERT MCCOY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 09/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 S 5TH AVE
MADILL OK
73446-3640
US

IV. Provider business mailing address

901 S 5TH AVE
MADILL OK
73446-3640
US

V. Phone/Fax

Practice location:
  • Phone: 580-795-3384
  • Fax: 580-795-0185
Mailing address:
  • Phone: 580-795-3384
  • Fax: 580-795-0185

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR0025463
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: