Healthcare Provider Details

I. General information

NPI: 1386817872
Provider Name (Legal Business Name): CMG FAMILY CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 S DEWEY AVE
WAGONER OK
74467-7013
US

IV. Provider business mailing address

1317 S DEWEY AVE
WAGONER OK
74467-7013
US

V. Phone/Fax

Practice location:
  • Phone: 918-485-9696
  • Fax: 918-485-1701
Mailing address:
  • Phone: 918-485-9696
  • Fax: 918-485-1701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21712
License Number StateOK

VIII. Authorized Official

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