Healthcare Provider Details

I. General information

NPI: 1447700422
Provider Name (Legal Business Name): ST ANTHONY PHYSICIANS GASTROENTEROLOGY MOB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

535 NW 9TH ST SUITE 325
OKLAHOMA CITY OK
73102-1070
US

IV. Provider business mailing address

535 NW 9TH ST SUITE 325
OKLAHOMA CITY OK
73102-1070
US

V. Phone/Fax

Practice location:
  • Phone: 405-601-6630
  • Fax: 405-601-6617
Mailing address:
  • Phone: 405-601-6630
  • Fax: 405-601-6617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL L PENA
Title or Position: INSURANCE CREDENTIALING SPECIALIST
Credential:
Phone: 405-272-7452