Healthcare Provider Details

I. General information

NPI: 1134386626
Provider Name (Legal Business Name): MUSKOGEE PHYSICIAN GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 05/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 ROCKEFELLER DR
MUSKOGEE OK
74401-5075
US

IV. Provider business mailing address

PO BOX 840633
DALLAS TX
75284-0633
US

V. Phone/Fax

Practice location:
  • Phone: 615-620-2320
  • Fax: 615-620-2323
Mailing address:
  • Phone: 615-620-2320
  • Fax: 615-620-2323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: SCOTT ROBERTS
Title or Position: BILLING MANAGER
Credential:
Phone: 615-620-2321