MEDICARE: DR. JEROME ANTHONY MCTAGUE MD, JD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207P00000X	Emergency Medicine Physician	30495	OK
2	207P00000X	Emergency Medicine Physician	2014015848	MO

General Provider Information

NPI Number	:	1194758540
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JEROME ANTHONY MCTAGUE MD, JD

Provider Business Mailing Address
First Line	:	2200 N CLASSEN BLVD
Second Line	:	SUITE 1403
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-5800
Country	:	US
Telephone Number	:	419-461-1057
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 N CLASSEN BLVD
Second Line	:	SUITE 1403
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73106-5800
Country	:	US
Telephone Number	:	419-461-1057
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	11/20/2014

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