MEDICARE: LMC MEDICAL GROUP 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	261QU0200X	Urgent Care Clinic/Center

General Provider Information

NPI Number	:	1548697550
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LMC MEDICAL GROUP LLC

Provider Business Mailing Address
First Line	:	932 W SHAWNEE ST
Second Line	:	SUITE A
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-3511
Country	:	US
Telephone Number	:	918-453-1234
Fax Number	:	918-453-9107

Provider Business Practice Location Address
First Line	:	932 W SHAWNEE ST
Second Line	:	SUITE A
City	:	MUSKOGEE
State	:	OK
Zip	:	74401-3511
Country	:	US
Telephone Number	:	918-453-1234
Fax Number	:	918-453-9107

Authorized Official
Title or Position	:	OWNER
Name	:	TRACEY W CHILDERS
Credential	:	D.O.
Telephone Number	:	918-453-1234

Provider Enumeration Date	:	10/04/2013
Last Update Date	:	10/17/2013

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Directions to “LMC MEDICAL GROUP LLC ” Practice Location

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