Basic Information
| Provider Information | |||||||||
| NPI: | 1750386223 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEMINOLE MEDICAL CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2403 W WRANGLER BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | SEMINOLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748681900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053824939 | ||||||||
| FaxNumber: | 4053824947 | ||||||||
| Practice Location | |||||||||
| Address1: | 2403 W WRANGLER BLVD | ||||||||
| Address2: | STE A | ||||||||
| City: | SEMINOLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748681900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053824939 | ||||||||
| FaxNumber: | 4053824947 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 06/13/2014 | ||||||||
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| AuthorizedOfficialLastName: | BUTNER | ||||||||
| AuthorizedOfficialFirstName: | TRICIA | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 4053824939 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | ARNP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 100748760A | 05 | OK | MEDICAID |