Provider Demographics
NPI:1215404108
Name:THE HEART CLINIC, P.C.
Entity Type:Organization
Organization Name:THE HEART CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAMWY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-348-9715
Mailing Address - Street 1:701 E DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74011-3575
Mailing Address - Country:US
Mailing Address - Phone:918-348-9715
Mailing Address - Fax:
Practice Address - Street 1:3720 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2141
Practice Address - Country:US
Practice Address - Phone:918-910-5301
Practice Address - Fax:918-910-5279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-10-29
Last Update Date:2019-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200041600AMedicaid