=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770382699
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PM MEDICAL LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2025
-----------------------------------------------------
Last Update Date | 05/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 W MAIN ST STE D
-----------------------------------------------------
City | STIGLER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74462-2304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-413-8542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 161
-----------------------------------------------------
City | MCCURTAIN
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74944-0161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-413-8542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER/EMPLOYEE
-----------------------------------------------------
Name | JEFF MCCLELLAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-413-8542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------