Healthcare Provider Details

I. General information

NPI: 1700904398
Provider Name (Legal Business Name): WARREN CLINIC MCALESTER PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 11/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E VAN BUREN AVE
MCALESTER OK
74501-4245
US

IV. Provider business mailing address

PO BOX 908
MCALESTER OK
74502-0908
US

V. Phone/Fax

Practice location:
  • Phone: 918-426-0240
  • Fax: 918-423-4051
Mailing address:
  • Phone: 918-426-0240
  • Fax: 918-423-4051

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBBIE NELSON
Title or Position: BUSINESS OPERATIONS MANAGER
Credential:
Phone: 918-426-0240