Provider Demographics
NPI:1346613833
Name:ST. MARY'S PHYSICIAN ASSOCIATES, LLC
Entity Type:Organization
Organization Name:ST. MARY'S PHYSICIAN ASSOCIATES, LLC
Other - Org Name:ST. MARY'S PODIATRY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:610-768-3300
Mailing Address - Street 1:PO BOX 844737
Mailing Address - Street 2:ATT: IPM CREDENTIALING
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4737
Mailing Address - Country:US
Mailing Address - Phone:855-298-6628
Mailing Address - Fax:903-416-1701
Practice Address - Street 1:1908 N 14TH STREET
Practice Address - Street 2:SUITE 203
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2039
Practice Address - Country:US
Practice Address - Phone:580-249-3929
Practice Address - Fax:580-234-3301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies