Basic Information
Provider Information | |||||||||
NPI: | 1275737397 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAINTS MEDICAL GROUP, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAINTS PEDIATRIC ASSOICATES | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 268851 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731268851 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052727337 | ||||||||
FaxNumber: | 4052313059 | ||||||||
Practice Location | |||||||||
Address1: | 608 NW 9TH ST | ||||||||
Address2: | 3000 | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731021068 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052727337 | ||||||||
FaxNumber: | 4052313059 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/13/2007 | ||||||||
LastUpdateDate: | 01/06/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BAIN | ||||||||
AuthorizedOfficialFirstName: | SYNOVIA | ||||||||
AuthorizedOfficialMiddleName: | FAITH | ||||||||
AuthorizedOfficialTitleorPosition: | CLIENT ACCOUNT ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 4052313824 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | SAINTS MEDICAL GROUP, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 200094240D | 05 | OK |   | MEDICAID |