Basic Information
| Provider Information | |||||||||
| NPI: | 1720325533 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINTS MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAINTS DERMATOLOGY CENTER OF EXCELLENCE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9720 BROADWAY EXTENSION | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052807546 | ||||||||
| FaxNumber: | 4057375901 | ||||||||
| Practice Location | |||||||||
| Address1: | 9720 BROADWAY EXTENSION | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052807546 | ||||||||
| FaxNumber: | 4057375901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2013 | ||||||||
| LastUpdateDate: | 01/14/2013 | ||||||||
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| AuthorizedOfficialLastName: | PENA | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4052727452 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTHCARE OF OK, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 22879 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.