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	License Number	License Number State
1	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1861774952
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAINTS MEDICAL GROUP, LLC

Provider Business Mailing Address
First Line	:	PO BOX 268986
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126-8986
Country	:	US
Telephone Number	:	405-732-2299
Fax Number	:	405-732-0899

Provider Business Practice Location Address
First Line	:	10002 SE 15TH ST
Second Line	:
City	:	MIDWEST CITY
State	:	OK
Zip	:	73130-5626
Country	:	US
Telephone Number	:	405-732-2299
Fax Number	:	405-732-0899

Authorized Official
Title or Position	:	INSURANCE CREDENTIALING SPECIALIST
Name	:	CRYSTAL L PENA
Credential	:
Telephone Number	:	405-272-7452

Provider Enumeration Date	:	09/14/2011
Last Update Date	:	09/14/2011

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