Basic Information
| Provider Information | |||||||||
| NPI: | 1306447172 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHAWNEE MEDICAL CENTER CLINIC, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SSM HEALTH SHAWNEE AMBULATORY CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4651 N HARRISON | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052735801 | ||||||||
| FaxNumber: | 4058783794 | ||||||||
| Practice Location | |||||||||
| Address1: | 4651 N HARRISON | ||||||||
| Address2: | |||||||||
| City: | SHAWNEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052735801 | ||||||||
| FaxNumber: | 4058783794 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2020 | ||||||||
| LastUpdateDate: | 11/20/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PENA | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4052727452 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE OF OKLAHOMA, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2085R0202X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.