Basic Information
| Provider Information | |||||||||
| NPI: | 1740603265 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. MARY'S PHYSICIAN ASSOCIATES, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3046 | ||||||||
| Address2: | |||||||||
| City: | MALVERN | ||||||||
| State: | PA | ||||||||
| PostalCode: | 193550746 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4849137434 | ||||||||
| FaxNumber: | 4849137587 | ||||||||
| Practice Location | |||||||||
| Address1: | 314 E OWEN K GARRIOTT RD | ||||||||
| Address2: | |||||||||
| City: | ENID | ||||||||
| State: | OK | ||||||||
| PostalCode: | 737015712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5802493929 | ||||||||
| FaxNumber: | 5802343301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2014 | ||||||||
| LastUpdateDate: | 06/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | TODD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP | ||||||||
| AuthorizedOfficialTelephone: | 6107683300 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 200111620M | 05 | OK | MEDICAID |