Provider Demographics
NPI:1093395618
Name:SAINTS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SAINTS MEDICAL GROUP, LLC
Other - Org Name:SSM HEALTH MEDICAL GROUP SHAWNEE KICKAPOO CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT - FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SHASTA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:MANUEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-272-7282
Mailing Address - Street 1:3700 N KICKAPOO AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1707
Mailing Address - Country:US
Mailing Address - Phone:405-273-6383
Mailing Address - Fax:405-273-3748
Practice Address - Street 1:3700 N KICKAPOO AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1707
Practice Address - Country:US
Practice Address - Phone:405-273-6383
Practice Address - Fax:405-273-3748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-08
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Multi-Specialty
No231H00000XSpeech, Language and Hearing Service ProvidersAudiologistGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty