Healthcare Provider Details

I. General information

NPI: 1487922993
Provider Name (Legal Business Name): SHAWNEE MEDICAL CENTER CLINIC, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2308 W HIGHWAY 66 SUITE B
STROUD OK
74079-6729
US

IV. Provider business mailing address

PO BOX 849
SHAWNEE OK
74802-0849
US

V. Phone/Fax

Practice location:
  • Phone: 918-968-4469
  • Fax: 918-968-1618
Mailing address:
  • Phone: 918-968-4469
  • Fax: 918-968-1618

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