Healthcare Provider Details

I. General information

NPI: 1073108460
Provider Name (Legal Business Name): SAINT MEDICAL GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2403 W WRANGLER BLVD
SEMINOLE OK
74868-1900
US

IV. Provider business mailing address

2403 W WRANGLER BLVD
SEMINOLE OK
74868-1900
US

V. Phone/Fax

Practice location:
  • Phone: 405-732-7020
  • Fax: 405-732-7839
Mailing address:
  • Phone: 405-732-7020
  • Fax: 405-732-7839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State

VIII. Authorized Official

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