=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407966575
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAMILY MEDICINE SPECIALISTS, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 07/26/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3700 N KICKAPOO AVE SUITE 124
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74804-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-273-6383
-----------------------------------------------------
Fax | 405-214-1075
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3700 N KICKAPOO AVE SUITE 124
-----------------------------------------------------
City | SHAWNEE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74804-1707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-273-6383
-----------------------------------------------------
Fax | 405-214-1075
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | TRACY MICHELLE FERRELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-273-6383
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------