MEDICARE: ABC MEDICAL CLINIC, INC 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
1	207Q00000X	Family Medicine Physician	2096	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1992995666
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABC MEDICAL CLINIC, INC PLLC

Provider Business Mailing Address
First Line	:	PO BOX 568
Second Line	:
City	:	ATOKA
State	:	OK
Zip	:	74525-0568
Country	:	US
Telephone Number	:	580-889-3355
Fax Number	:	580-889-5272

Provider Business Practice Location Address
First Line	:	1510 S VIRGINIA AVE
Second Line	:
City	:	ATOKA
State	:	OK
Zip	:	74525-3246
Country	:	US
Telephone Number	:	580-889-3355
Fax Number	:	580-927-9941

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MS. LINDA L HEINZE
Credential	:
Telephone Number	:	580-889-3355

Provider Enumeration Date	:	07/30/2007
Last Update Date	:	05/09/2013

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