Provider Demographics
NPI:1154489540
Name:CMS OUTPATIENT CLINIC INC.
Entity Type:Organization
Organization Name:CMS OUTPATIENT CLINIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R,
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-310-0015
Mailing Address - Street 1:201 N MONTE VISTA ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-7220
Mailing Address - Country:US
Mailing Address - Phone:580-310-0015
Mailing Address - Fax:580-310-0909
Practice Address - Street 1:201 N MONTE VISTA ST
Practice Address - Street 2:SUITE C
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-7220
Practice Address - Country:US
Practice Address - Phone:580-310-0015
Practice Address - Fax:580-310-0909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200039450BMedicaid
OK200039450AMedicaid
OK200039450BMedicaid