Healthcare Provider Details

I. General information

NPI: 1659568301
Provider Name (Legal Business Name): CMG FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2007
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 E ROSS BYP SUITE A
TAHLEQUAH OK
74464-4133
US

IV. Provider business mailing address

1203 E ROSS BYP SUITE A
TAHLEQUAH OK
74464-4133
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-1234
  • Fax: 918-453-9107
Mailing address:
  • Phone: 918-453-1234
  • Fax: 918-453-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR0067005
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier600522432
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerMEDICARE GROUP NUMBER

VIII. Authorized Official

Name: LISA A SWARER
Title or Position: MANAGER
Credential:
Phone: 918-453-1234