=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235867938
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUTHERN PLAINS MEDICAL CENTER OF GARVIN COUNTY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/10/2022
-----------------------------------------------------
Last Update Date | 10/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1218 E 9TH ST STE 1
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-5796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-888-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1218 E 9TH ST STE 1
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73034-5796
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-888-5000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. MADHUKAR SHARMA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 979-399-4966
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------