Healthcare Provider Details

I. General information

NPI: 1467631903
Provider Name (Legal Business Name): JEANNIE M MC CANCE MD PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

826 E BROADWAY ST
MUSKOGEE OK
74403-5124
US

IV. Provider business mailing address

826 E BROADWAY ST
MUSKOGEE OK
74403-5124
US

V. Phone/Fax

Practice location:
  • Phone: 918-687-1634
  • Fax: 918-398-4408
Mailing address:
  • Phone: 918-687-1634
  • Fax: 918-398-4408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License Number16881
License Number StateOK

VIII. Authorized Official

Name: MRS. JEANNIE M MC CANCE
Title or Position: OWNER
Credential: M.D.
Phone: 918-687-1634