Basic Information
| Provider Information | |||||||||
| NPI: | 1093013948 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINTS MEDICAL GROUP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAINTS DERMATOLOGY ENID | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 S 5TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737015825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802422386 | ||||||||
| FaxNumber: | 5802335312 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 S 5TH ST | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737015825 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802422386 | ||||||||
| FaxNumber: | 5802335312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2011 | ||||||||
| LastUpdateDate: | 07/29/2011 | ||||||||
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| AuthorizedOfficialLastName: | PENA | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4052727452 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTHCARE OF OK, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.