Basic Information
| Provider Information | |||||||||
| NPI: | 1386823102 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINTS MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAINTS INTERNAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268975 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268975 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052724953 | ||||||||
| FaxNumber: | 4052724956 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 N LEE AVE | ||||||||
| Address2: | SUITE 334 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731032600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052724953 | ||||||||
| FaxNumber: | 4052724956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 04/15/2010 | ||||||||
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| AuthorizedOfficialLastName: | BAIN | ||||||||
| AuthorizedOfficialFirstName: | KATY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CLIENT ACCOUNT REPRESENTATIVE | ||||||||
| AuthorizedOfficialTelephone: | 4052313817 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINTS MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200094240L | 05 | OK | MEDICAID |