MEDICARE: SAINTS MEDICAL GROUP, LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207YX0901X	Otology & Neurotology Physician
2	231H00000X	Audiologist
3	207Y00000X	Otolaryngology Physician

General Provider Information

NPI Number	:	1396343281
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINTS MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	13401 N WESTERN AVE STE 404
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-1412
Country	:	US
Telephone Number	:	405-608-4440
Fax Number	:	405-607-3546

Provider Business Practice Location Address
First Line	:	13401 N WESTERN AVE STE 404
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73114-1412
Country	:	US
Telephone Number	:	405-608-4440
Fax Number	:	405-607-3546

Authorized Official
Title or Position	:	PROVIDER ENROLLMENT COORDINATOR
Name	:	CRYSTAL L PENA
Credential	:
Telephone Number	:	405-272-7452

Provider Enumeration Date	:	10/13/2020
Last Update Date	:	02/08/2021

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