Healthcare Provider Details

I. General information

NPI: 1689987588
Provider Name (Legal Business Name): MCBRIDE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2010
Last Update Date: 07/20/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 36TH AVE NW
NORMAN OK
73072-1803
US

IV. Provider business mailing address

1110 N LEE AVE
OKLAHOMA CITY OK
73103-2612
US

V. Phone/Fax

Practice location:
  • Phone: 405-230-9600
  • Fax: 405-230-9601
Mailing address:
  • Phone: 405-230-9000
  • Fax: 405-230-9475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. MARK A. GALLIART
Title or Position: CEO
Credential:
Phone: 405-230-9000