Healthcare Provider Details

I. General information

NPI: 1629489612
Provider Name (Legal Business Name): OKLAHOMA MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2014
Last Update Date: 04/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10317 GREENBRIAR PKWY
OKLAHOMA CITY OK
73159-7648
US

IV. Provider business mailing address

10317 GREENBRIAR PKWY
OKLAHOMA CITY OK
73159-7648
US

V. Phone/Fax

Practice location:
  • Phone: 405-378-3400
  • Fax: 186-632-3795
Mailing address:
  • Phone: 405-378-3400
  • Fax: 866-323-7959

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. TRACY ELLIS
Title or Position: MEMBER
Credential:
Phone: 405-664-7622