Basic Information
| Provider Information | |||||||||
| NPI: | 1710160866 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINTS MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHESAPEAKE HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 268990 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731268990 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052182500 | ||||||||
| FaxNumber: | 4052182560 | ||||||||
| Practice Location | |||||||||
| Address1: | 924 NW 58TH ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731185915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052182500 | ||||||||
| FaxNumber: | 4052182560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2007 | ||||||||
| LastUpdateDate: | 11/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | BAIN | ||||||||
| AuthorizedOfficialFirstName: | SYNOVIA | ||||||||
| AuthorizedOfficialMiddleName: | FAITH | ||||||||
| AuthorizedOfficialTitleorPosition: | CLIENT ACCOUNT ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4052313824 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAINTS MEDICAL GROUP, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.