Healthcare Provider Details

I. General information

NPI: 1053380287
Provider Name (Legal Business Name): CARDIOLOGY CLINIC OF MUSKOGEE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 S 40TH ST CCOM MEDICAL GROUP
MUSKOGEE OK
74401-4915
US

IV. Provider business mailing address

350 S 40TH ST CCOM MEDICAL GROUP
MUSKOGEE OK
74401-4915
US

V. Phone/Fax

Practice location:
  • Phone: 918-683-0753
  • Fax:
Mailing address:
  • Phone: 918-683-0753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ANN BARKER ONG
Title or Position: CORPORATE SECRETARY
Credential:
Phone: 918-683-0753