Healthcare Provider Details

I. General information

NPI: 1013972884
Provider Name (Legal Business Name): PHILLIP WAYNE HALCUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 KERR AVE
POTEAU OK
74953-5270
US

IV. Provider business mailing address

8625 COVE CIR
HACKETT AR
72937-4161
US

V. Phone/Fax

Practice location:
  • Phone: 918-649-1100
  • Fax: 918-649-1199
Mailing address:
  • Phone: 501-690-0298
  • Fax: 918-649-1199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberC-7091
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number91-62
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: