Healthcare Provider Details

I. General information

NPI: 1497960009
Provider Name (Legal Business Name): OWASSO MEDICAL FACILITY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12451 E 100TH ST N
OWASSO OK
74055-4600
US

IV. Provider business mailing address

12451 E 100TH ST N
OWASSO OK
74055-4600
US

V. Phone/Fax

Practice location:
  • Phone: 918-274-5000
  • Fax:
Mailing address:
  • Phone: 918-274-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number2374
License Number StateOK

VIII. Authorized Official

Name: MR. DAVID L PHILLIPS
Title or Position: CEO
Credential:
Phone: 918-744-2113