Basic Information
| Provider Information | |||||||||
| NPI: | 1346613833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. MARY'S PHYSICIAN ASSOCIATES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ST. MARY'S PODIATRY CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844737 | ||||||||
| Address2: | ATT: IPM CREDENTIALING | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8552986628 | ||||||||
| FaxNumber: | 9034161701 | ||||||||
| Practice Location | |||||||||
| Address1: | 1908 N 14TH STREET | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | PONCA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 746012039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802493929 | ||||||||
| FaxNumber: | 5802343301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2015 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6107683300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
No ID Information.