Healthcare Provider Details

I. General information

NPI: 1952533648
Provider Name (Legal Business Name): R. MICHAEL EIMEN, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2009
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date: 03/17/2010
Reactivation Date: 07/21/2010

III. Provider practice location address

500 CIMARRON DR
MANNFORD OK
74044-9504
US

IV. Provider business mailing address

PO BOX 323
MANNFORD OK
74044-0323
US

V. Phone/Fax

Practice location:
  • Phone: 918-865-5000
  • Fax: 918-865-5050
Mailing address:
  • Phone: 918-865-5000
  • Fax: 918-865-5050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2520
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA1777
License Number StateOK

VIII. Authorized Official

Name: VICKI EIMEN
Title or Position: BUSINESS MANAGER
Credential:
Phone: 918-865-5000