Basic Information
| Provider Information | |||||||||
| NPI: | 1841659125 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST ANTHONY PHYSICIANS DERMATOLOGY MIDWEST CITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SAINTS MEDICAL GROUP, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1622 MIDTOWN PLACE | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731305266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052807546 | ||||||||
| FaxNumber: | 4057728674 | ||||||||
| Practice Location | |||||||||
| Address1: | 1622 MIDTOWN PLACE | ||||||||
| Address2: | |||||||||
| City: | MIDWEST CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731305266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052807546 | ||||||||
| FaxNumber: | 4057728674 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2016 | ||||||||
| LastUpdateDate: | 02/16/2016 | ||||||||
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| AuthorizedOfficialLastName: | PENA | ||||||||
| AuthorizedOfficialFirstName: | CRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | INSURANCE CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 4052727452 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SSM HEALTH CARE OF OKLAHOMA, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.