Healthcare Provider Details

I. General information

NPI: 1093986937
Provider Name (Legal Business Name): BLACKHAWK MANGUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2008
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE WICKERSHAM DR
MANGUM OK
73554
US

IV. Provider business mailing address

PO BOX 280
MANGUM OK
73554
US

V. Phone/Fax

Practice location:
  • Phone: 580-782-3353
  • Fax: 580-782-2811
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2208
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2208
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2208
License Number StateOK
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2208
License Number StateOK

VIII. Authorized Official

Name: SHANA DAVENPORT
Title or Position: INSURANCE CREDENTIALING SUPERVISOR
Credential:
Phone: 512-681-3460