Healthcare Provider Details

I. General information

NPI: 1770178170
Provider Name (Legal Business Name): SHAWNEE MEDICAL CENTER CLINIC, INC
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

1102 W MACARTHUR ST
SHAWNEE OK
74804-1743
US

IV. Provider business mailing address

1102 W MACARTHUR ST
SHAWNEE OK
74804-1743
US

V. Phone/Fax

Practice location:
  • Phone: 405-272-7311
  • Fax: 405-272-6962
Mailing address:
  • Phone: 405-272-7311
  • Fax: 405-272-6962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2471R0002X
TaxonomyRadiation Therapy Radiologic Technologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

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