Basic Information
| Provider Information | |||||||||
| NPI: | 1134688146 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINTS MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 535 NW 9TH ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052728498 | ||||||||
| FaxNumber: | 4052728425 | ||||||||
| Practice Location | |||||||||
| Address1: | 535 NW 9TH ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731021072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052728498 | ||||||||
| FaxNumber: | 4052728425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2019 | ||||||||
| LastUpdateDate: | 03/19/2019 | ||||||||
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| AuthorizedOfficialLastName: | PENA | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 4052727452 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE OF OKLAHOMA, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.