=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174777940
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATKINSON MEDICAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2008
-----------------------------------------------------
Last Update Date | 12/06/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5606 SW LEE BLVD SUITE 305
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505-9688
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-248-1055
-----------------------------------------------------
Fax | 580-699-8010
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5606 SW LEE BLVD SUITE 305
-----------------------------------------------------
City | LAWTON
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 580-248-1055
-----------------------------------------------------
Fax | 580-699-8010
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | THOMAS B ATKINSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 580-248-1055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 21702
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------