Basic Information
| Provider Information | |||||||||
| NPI: | 1033255039 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINTS MEDICAL GROUP, LLC | ||||||||
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| OtherOrganizationName: | SAINTS FAMILY MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268824 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052313000 | ||||||||
| FaxNumber: | 4052313073 | ||||||||
| Practice Location | |||||||||
| Address1: | 608 NW 9TH ST | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021068 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052313000 | ||||||||
| FaxNumber: | 4052313073 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 02/11/2010 | ||||||||
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| AuthorizedOfficialLastName: | BAIN | ||||||||
| AuthorizedOfficialFirstName: | KATY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLIENT ACCOUNT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4052313817 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINTS MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200094240Q | 05 | OK | MEDICAID |