Basic Information
| Provider Information | |||||||||
| NPI: | 1396959482 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY MED LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2004 N HIGHWAY 81 | ||||||||
| Address2: | |||||||||
| City: | DUNCAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735331460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802520500 | ||||||||
| FaxNumber: | 5802521020 | ||||||||
| Practice Location | |||||||||
| Address1: | 2004 N HIGHWAY 81 | ||||||||
| Address2: | |||||||||
| City: | DUNCAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735331460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802520500 | ||||||||
| FaxNumber: | 5802521020 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2007 | ||||||||
| LastUpdateDate: | 05/15/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GREGSTON | ||||||||
| AuthorizedOfficialFirstName: | JAY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 5802520500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100118660F | 05 | OK | MEDICAID | 100254370B | 05 | OK | MEDICAID | 20116880A | 05 | OK | MEDICAID | 586187246001 | 01 | OK | BCBS PIN | OTHER | 200116880B | 05 | OK | MEDICAID |