Healthcare Provider Details

I. General information

NPI: 1346824679
Provider Name (Legal Business Name): SAINT MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2021
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 S DOUGLAS BLVD
OKLAHOMA CITY OK
73130-5246
US

IV. Provider business mailing address

1212 S DOUGLAS BLVD
OKLAHOMA CITY OK
73130-5246
US

V. Phone/Fax

Practice location:
  • Phone: 405-736-6811
  • Fax: 405-736-6863
Mailing address:
  • Phone: 405-736-6811
  • Fax: 405-736-6863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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