Basic Information
| Provider Information | |||||||||
| NPI: | 1881985109 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STILLWATER FAMILYCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1119 | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740761119 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187288266 | ||||||||
| FaxNumber: | 9187283021 | ||||||||
| Practice Location | |||||||||
| Address1: | 1921 W 6TH AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740744204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055332433 | ||||||||
| FaxNumber: | 4055332434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/20/2011 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | SMITHTON | ||||||||
| AuthorizedOfficialFirstName: | CORBY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 4055992433 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.