Basic Information
| Provider Information | |||||||||
| NPI: | 1558603738 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KP MEDICAL GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2301 W I 44 SERVICE RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731128729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056072233 | ||||||||
| FaxNumber: | 4052861303 | ||||||||
| Practice Location | |||||||||
| Address1: | 2301 W I 44 SERVICE RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731128729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056072233 | ||||||||
| FaxNumber: | 4052861303 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2013 | ||||||||
| LastUpdateDate: | 03/05/2015 | ||||||||
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| AuthorizedOfficialLastName: | PEYTON | ||||||||
| AuthorizedOfficialFirstName: | MARVIN | ||||||||
| AuthorizedOfficialMiddleName: | LANE | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4057534994 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | OK24005 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
No ID Information.