Healthcare Provider Details

I. General information

NPI: 1760077499
Provider Name (Legal Business Name): SAINTS MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2021
Last Update Date: 03/04/2021
Certification Date: 02/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 S DOUGLAS BLVD
OKLAHOMA CITY OK
73130-6224
US

IV. Provider business mailing address

1800 S DOUGLAS BLVD
OKLAHOMA CITY OK
73130-6224
US

V. Phone/Fax

Practice location:
  • Phone: 405-741-7722
  • Fax: 405-741-7757
Mailing address:
  • Phone: 405-741-7722
  • Fax: 405-741-7757

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 Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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