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NPI Code Detail

MEDICARE: BLUE STAR MEDICAL GROUP PLLC

MEDICARE: BLUE STAR MEDICAL GROUP PLLC
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
1174400000XSpecialist

General Provider Information

NPI Number : 1619126489
Entity Type Code : Organization
Provider Name (Legal Business Name) : BLUE STAR MEDICAL GROUP PLLC
Provider Business Mailing Address
First Line : 3115 SW 89TH ST
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73159-7901
Country : US
Telephone Number : 405-424-5630
Fax Number :
Provider Business Practice Location Address
First Line : 3115 SW 89TH ST
Second Line :
City : OKLAHOMA CITY
State : OK
Zip : 73159-7901
Country : US
Telephone Number : 405-424-5630
Fax Number :
Authorized Official
Title or Position : ADMINISTRATOR
Name : GLENDA COHRS
Credential :
Telephone Number : 405-424-5630
Provider Enumeration Date : 09/16/2008
Last Update Date : 09/16/2008

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Directions to “BLUE STAR MEDICAL GROUP PLLC ” Practice Location

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