MEDICARE: EXPRESSWAY CLINIC, 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	207Q00000X	Family Medicine Physician	18631	OK

General Provider Information

NPI Number	:	1841569217
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXPRESSWAY CLINIC, LLC

Provider Business Mailing Address
First Line	:	8105 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-6004
Country	:	US
Telephone Number	:	405-602-3500
Fax Number	:	405-602-3550

Provider Business Practice Location Address
First Line	:	8105 NW EXPRESSWAY
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73162-6004
Country	:	US
Telephone Number	:	405-602-3500
Fax Number	:	405-602-3550

Authorized Official
Title or Position	:	MANAGER
Name	:	ANDREW HOELSCHER
Credential	:	MD
Telephone Number	:	866-556-5102

Provider Enumeration Date	:	12/14/2011
Last Update Date	:	11/09/2015

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