MEDICARE: FIRST MED CLINIC PENN LLC

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1205275880
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST MED CLINIC PENN LLC

Provider Business Mailing Address
First Line	:	1221 N KELLY AVE
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73003-4865
Country	:	US
Telephone Number	:	405-471-6400
Fax Number	:

Provider Business Practice Location Address
First Line	:	13420 N PENNSYLVANIA AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73120-9007
Country	:	US
Telephone Number	:	405-478-0633
Fax Number	:	405-478-5218

Authorized Official
Title or Position	:	CEO
Name	:	TODD LECHTENBERGER
Credential	:
Telephone Number	:	405-471-6400

Provider Enumeration Date	:	06/18/2013
Last Update Date	:	06/18/2013

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