Provider Demographics
NPI:1275953820
Name:PRIMARY CARE MEDICAL CLINIC PLC
Entity Type:Organization
Organization Name:PRIMARY CARE MEDICAL CLINIC PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SHANE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-941-8245
Mailing Address - Street 1:13600 PRAIRIE VIEW LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-5917
Mailing Address - Country:US
Mailing Address - Phone:888-330-7831
Mailing Address - Fax:888-330-7831
Practice Address - Street 1:13600 PRAIRIE VIEW LN
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-5917
Practice Address - Country:US
Practice Address - Phone:888-330-7831
Practice Address - Fax:888-330-7831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK30380261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care