Basic Information
| Provider Information | |||||||||
| NPI: | 1144990342 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DIRECT CARE MEDICAL GROUP, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13045 S KELLY AVE UNIT BB | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730251915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059423737 | ||||||||
| FaxNumber: | 4059423873 | ||||||||
| Practice Location | |||||||||
| Address1: | 13045 S KELLY AVE UNIT BB | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730251915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059423737 | ||||||||
| FaxNumber: | 4059423873 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2021 | ||||||||
| LastUpdateDate: | 09/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | BISHOP | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4059423737 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 09/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.