Healthcare Provider Details

I. General information

NPI: 1104462167
Provider Name (Legal Business Name): SHAWNEE MEDICAL CENTER CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/25/2019
Last Update Date: 11/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 KETHLEY RD
SHAWNEE OK
74804-9638
US

IV. Provider business mailing address

3315 KETHLEY RD
SHAWNEE OK
74804-9638
US

V. Phone/Fax

Practice location:
  • Phone: 405-273-5801
  • Fax: 405-878-3794
Mailing address:
  • Phone: 405-273-5801
  • Fax: 405-878-3794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

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