=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982692216
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLAREMORE PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2005
-----------------------------------------------------
Last Update Date | 03/04/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1202 N MUSKOGEE PL
-----------------------------------------------------
City | CLAREMORE
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74017-3058
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-392-4456
-----------------------------------------------------
Fax | 918-392-4485
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7100 COMMERCE WAY SUITE 180
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-2829
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PROVIDER ENROLLMENT
-----------------------------------------------------
Name | MS. DEBBIE BREWER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-892-9813
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------