Healthcare Provider Details

I. General information

NPI: 1457972366
Provider Name (Legal Business Name): SAINT MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/01/2020
Last Update Date: 05/01/2020
Certification Date: 05/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 S DOUGLAS BLVD STE 307A
OKLAHOMA CITY OK
73150-1001
US

IV. Provider business mailing address

3400 S DOUGLAS BLVD STE 307A
OKLAHOMA CITY OK
73150-1001
US

V. Phone/Fax

Practice location:
  • Phone: 405-218-2582
  • Fax: 405-218-2587
Mailing address:
  • Phone: 405-218-2582
  • Fax: 405-218-2587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

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