MEDICARE: DR. JAN RUSSELL HILL M.D.

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	19188	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5350485	OTHER	OK	AETNA

General Provider Information

NPI Number	:	1871561696
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAN RUSSELL HILL M.D.

Provider Business Mailing Address
First Line	:	1715 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2763
Country	:	US
Telephone Number	:	580-762-9292
Fax Number	:	580-762-1660

Provider Business Practice Location Address
First Line	:	1715 N 5TH ST
Second Line	:
City	:	PONCA CITY
State	:	OK
Zip	:	74601-2763
Country	:	US
Telephone Number	:	580-762-9292
Fax Number	:	580-762-1660

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2006
Last Update Date	:	11/15/2010

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