=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427240118
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHANDLER CLINIC A DIVISION OF PLAZA MEDICAL GROUP, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/16/2007
-----------------------------------------------------
Last Update Date | 08/16/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 114 N HIGHWAY 18
-----------------------------------------------------
City | CHANDLER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74834-1200
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-258-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3433 NW 56TH ST STE 400
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73112-4430
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-948-4040
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | PAUL SYZMANSKI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 405-948-4040
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 2298
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------