1063525954 NPI number — CANYON PARK MEDICAL GROUP, PLLC

Table of content: (NPI 1063525954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063525954 NPI number — CANYON PARK MEDICAL GROUP, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANYON PARK MEDICAL GROUP, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063525954
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 E 19TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EDMOND
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73013-6618
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-348-6611
Provider Business Mailing Address Fax Number:
405-348-9280

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1501 E 19TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EDMOND
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73013-6618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-348-6611
Provider Business Practice Location Address Fax Number:
405-348-9280
Provider Enumeration Date:
08/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KEITH
Authorized Official First Name:
TONYA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
405-348-6611

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  8699 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 37DO469469 . This is a "CLIA #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: CH5055 . This is a "RAILROAD MEDICARE #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 100748060A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4589400001 . This is a "DMERC GROUP #" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




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