1508096447 NPI number — TISHOMINGO DOCTOR'S MEDICAL CLINIC, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508096447 NPI number — TISHOMINGO DOCTOR'S MEDICAL CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TISHOMINGO DOCTOR'S MEDICAL CLINIC, PC
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:
1508096447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/20/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
508 E 24TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TISHOMINGO
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73460-3214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-371-9117
Provider Business Mailing Address Fax Number:
580-371-3170

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
508 E 24TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TISHOMINGO
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73460-3214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-371-9117
Provider Business Practice Location Address Fax Number:
580-371-3170
Provider Enumeration Date:
07/24/2009

Additional Information

Authorized Official

Authorized Official Last Name:
RAGAN
Authorized Official First Name:
VIRGINIA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
580-371-9117

Provider Taxonomy Codes

  • Taxonomy code: 261QM1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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