Basic Information
| Provider Information | |||||||||
| NPI: | 1235209453 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHERN PLAINS MEDICAL CTR PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1104 E CENTRAL BLVD | ||||||||
| Address2: | |||||||||
| City: | ANADARKO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730054406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052476685 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1104 E CENTRAL BLVD | ||||||||
| Address2: | |||||||||
| City: | ANADARKO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730054406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052476685 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2006 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GASPARD | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4052248111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | OK | Y | Laboratories | Clinical Medical Laboratory |
No ID Information.