Healthcare Provider Details

I. General information

NPI: 1396399796
Provider Name (Legal Business Name): SAINT MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2019
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 NW 9TH ST STE 5010
OKLAHOMA CITY OK
73102-1058
US

IV. Provider business mailing address

608 NW 9TH ST STE 5010
OKLAHOMA CITY OK
73102-1058
US

V. Phone/Fax

Practice location:
  • Phone: 405-815-5680
  • Fax: 405-815-5685
Mailing address:
  • Phone: 405-815-5680
  • Fax: 405-815-5685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS1201X
TaxonomySleep Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL L PENA
Title or Position: PROVIDER ENROLLMENT/CREDENTIALING
Credential:
Phone: 405-272-7452