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General NPI Number Information
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NPI Number | 1134387855
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Entity Type | Organization
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Legal Business Name | SELF PROVIDER GROUP
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Dates
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Enumeration Date | 05/29/2008
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Last Update Date | 05/29/2008
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Provider Practice Location Address
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Address Line | 410 4TH ST STE G
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City | ALVA
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State | OK
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Zip | 73717-2372
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Country | US
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Telephone | 580-327-5442
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Fax | 580-327-2207
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Provider Business Mailing Address
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Address Line | 410 4TH ST STE G
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City | ALVA
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State | OK
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Zip | 73717-2372
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Country | US
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Telephone | 580-327-5442
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Fax | 580-327-2207
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | LISA M MCMURPHY
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Credential | PHD
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Telephone | 580-327-5442
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 14793
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License Number State | OK
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