MEDICARE: MIDWEST CITY HMA PHYSICIAN MANAGEMENT, 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	363A00000X	Physician Assistant
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1437404167
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDWEST CITY HMA PHYSICIAN MANAGEMENT, LLC

Provider Business Mailing Address
First Line	:	5811 PELICAN BAY BLVD
Second Line	:	SUITE 500
City	:	NAPLES
State	:	FL
Zip	:	34108-2733
Country	:	US
Telephone Number	:	239-598-3131
Fax Number	:	239-592-0438

Provider Business Practice Location Address
First Line	:	20826 MAIN ST
Second Line	:
City	:	HARRAH
State	:	OK
Zip	:	73045-9756
Country	:	US
Telephone Number	:	405-454-2404
Fax Number	:	405-454-6372

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	MR. MICHAEL L GINGRAS
Credential	:
Telephone Number	:	239-598-3131

Provider Enumeration Date	:	07/18/2012
Last Update Date	:	11/27/2012

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