MEDICARE: CHAUNCEY B WITCRAFT MD PC

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	261QM2500X	Medical Specialty Clinic/Center	13131	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	363287549002	OTHER	OK	BLUE CROSS BLUE SHIELD-OK

General Provider Information

NPI Number	:	1285852947
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHAUNCEY B WITCRAFT MD PC

Provider Business Mailing Address
First Line	:	310 2ND AVE SW STE 105
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-6708
Country	:	US
Telephone Number	:	918-542-2812
Fax Number	:	918-542-2814

Provider Business Practice Location Address
First Line	:	310 2ND AVE SW STE 105
Second Line	:
City	:	MIAMI
State	:	OK
Zip	:	74354-6708
Country	:	US
Telephone Number	:	918-542-2812
Fax Number	:	918-542-2814

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHAUNCEY B WITCRAFT III
Credential	:	MD
Telephone Number	:	918-542-2812

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	10/04/2007

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