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General NPI Number Information
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NPI Number | 1568369700
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Entity Type | Organization
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Legal Business Name | GENESIS MEDICAL PLLC
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Dates
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Enumeration Date | 10/21/2026
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Last Update Date | 10/21/2026
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Provider Practice Location Address
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Address Line | 698 WESTSIDE DR STE 102
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City | DURANT
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State | OK
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Zip | 74701-3085
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Country | US
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Telephone | 580-221-2022
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Fax |
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Provider Business Mailing Address
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Address Line | 2002 12TH AVE NW STE B
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City | ARDMORE
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State | OK
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Zip | 73401-1206
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING, BILLING
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Name | SHERRY LYNNE CLARK
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Credential |
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Telephone | 580-223-5180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207LP2900X
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Taxonomy Name | Pain Medicine (Anesthesiology) Physician
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number |
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License Number State |
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