Basic Information
| Provider Information | |||||||||
| NPI: | 1760450480 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAW | ||||||||
| FirstName: | MAGGIE | ||||||||
| MiddleName: | S.W. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 S 40TH ST | ||||||||
| Address2: | CCOM MEDICAL GROUP | ||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186830753 | ||||||||
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| Practice Location | |||||||||
| Address1: | 350 S 40TH ST | ||||||||
| Address2: | CCOM MEDICAL GROUP | ||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186830753 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2006 | ||||||||
| LastUpdateDate: | 04/01/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 19934 | OK | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100224720A | 05 | OK | MEDICAID |