Basic Information
| Provider Information | |||||||||
| NPI: | 1205301231 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SHAWNEE MEDICAL CENTER CLINIC, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3315 KETHLEY RD | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748049638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052735801 | ||||||||
| FaxNumber: | 4058783794 | ||||||||
| Practice Location | |||||||||
| Address1: | 3315 KETHLEY RD | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748049638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052735801 | ||||||||
| FaxNumber: | 4058783794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2018 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | PENA | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4052727452 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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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.