Provider Demographics
NPI:1235259573
Name:COLLINSVILLE FAMILY CLINIC, INC.
Entity Type:Organization
Organization Name:COLLINSVILLE FAMILY CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:PATTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-371-6022
Mailing Address - Street 1:1205 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74021-3114
Mailing Address - Country:US
Mailing Address - Phone:918-371-6022
Mailing Address - Fax:918-371-3168
Practice Address - Street 1:1205 W MAIN ST
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:OK
Practice Address - Zip Code:74021-3114
Practice Address - Country:US
Practice Address - Phone:918-371-6022
Practice Address - Fax:918-371-3168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-30
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1872207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1801890454OtherNPI INDIVIDUAL
OK100251820AMedicaid
OK1801890454OtherNPI INDIVIDUAL
OKE09745Medicare UPIN