Healthcare Provider Details

I. General information

NPI: 1598054330
Provider Name (Legal Business Name): MEDICINE WHEEL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2011
Last Update Date: 05/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 WEST F STREET
MILBURN OK
73450
US

IV. Provider business mailing address

PO BOX 67
MILBURN OK
73450-0067
US

V. Phone/Fax

Practice location:
  • Phone: 580-443-3533
  • Fax: 580-443-3536
Mailing address:
  • Phone: 508-443-3533
  • Fax: 580-443-3536

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2982
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2982
License Number StateOK

VIII. Authorized Official

Name: PAUL E WEATHERS
Title or Position: MEDICAL DIRECTER
Credential: D.O.
Phone: 580-443-3533