Provider Demographics
NPI:1164541900
Name:INTERNAL MEDICINE CLINIC PLLC
Entity Type:Organization
Organization Name:INTERNAL MEDICINE CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:J
Authorized Official - Last Name:LIM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-338-5500
Mailing Address - Street 1:PO BOX 158
Mailing Address - Street 2:410 NE 12TH STREET
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-0158
Mailing Address - Country:US
Mailing Address - Phone:580-338-5500
Mailing Address - Fax:580-468-4942
Practice Address - Street 1:410 NE 12TH STREET
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942
Practice Address - Country:US
Practice Address - Phone:580-338-5500
Practice Address - Fax:580-468-4942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18750207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF72495Medicare UPIN