Healthcare Provider Details

I. General information

NPI: 1063520260
Provider Name (Legal Business Name): PERRY FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 14TH ST
PERRY OK
73077
US

IV. Provider business mailing address

505 14TH ST
PERRY OK
73077
US

V. Phone/Fax

Practice location:
  • Phone: 580-336-3529
  • Fax:
Mailing address:
  • Phone: 580-336-3529
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MICHAEL D HARTWIG
Title or Position: PARTNER
Credential: MD
Phone: 580-336-3529