Healthcare Provider Details

I. General information

NPI: 1144307554
Provider Name (Legal Business Name): MIDWAY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

351 N AIR DEPOT BLVD SUITE BB
MIDWEST CITY OK
73110-1700
US

IV. Provider business mailing address

PO BOX 30739
MIDWEST CITY OK
73140
US

V. Phone/Fax

Practice location:
  • Phone: 405-610-3600
  • Fax: 405-610-3607
Mailing address:
  • Phone: 405-610-3600
  • Fax: 405-610-3607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MCKINLEY BOATNER
Title or Position: CEO
Credential: PA
Phone: 405-610-3600