Basic Information
| Provider Information | |||||||||
| NPI: | 1831144468 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NOBLE FAMILY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 N MONTE VISTA ST | ||||||||
| Address2: | |||||||||
| City: | ADA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 748204612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803109510 | ||||||||
| FaxNumber: | 5804364447 | ||||||||
| Practice Location | |||||||||
| Address1: | 501 E MAGUIRE RD | ||||||||
| Address2: | STE 4000 | ||||||||
| City: | NOBLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730689403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058729494 | ||||||||
| FaxNumber: | 4058729464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 06/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | MEYER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4058729494 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ADA FAMILY MEDICAL CENTER, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20674 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200015950E | 05 | OK | MEDICAID |