Basic Information
| Provider Information | |||||||||
| NPI: | 1972005981 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STILLWATER MEDICAL CENTER AUTHORITY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | COMMUNITY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 720006 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4055336057 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1318 ELM ST | ||||||||
| Address2: | |||||||||
| City: | PERRY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730775034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5803369411 | ||||||||
| FaxNumber: | 5803369422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2018 | ||||||||
| LastUpdateDate: | 03/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | WEBBER | ||||||||
| AuthorizedOfficialFirstName: | DENISE | ||||||||
| AuthorizedOfficialMiddleName: | ADRIENNE | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4057425230 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.