Basic Information
| Provider Information | |||||||||
| NPI: | 1174547632 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMANCHE COUNTY HEALTHCARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEMORIAL MEDICAL GROUP FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 785 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803579984 | ||||||||
| FaxNumber: | 5803573277 | ||||||||
| Practice Location | |||||||||
| Address1: | 3201 W GORE BLVD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805107077 | ||||||||
| FaxNumber: | 5805107057 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 09/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | BLACKMON | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5803558620 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 22720 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.