Provider Demographics
NPI:1386817872
Name:CMG FAMILY CLINIC
Entity Type:Organization
Organization Name:CMG FAMILY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPERATIONS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWARER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-1234
Mailing Address - Street 1:1317 S DEWEY AVE
Mailing Address - Street 2:
Mailing Address - City:WAGONER
Mailing Address - State:OK
Mailing Address - Zip Code:74467-7013
Mailing Address - Country:US
Mailing Address - Phone:918-485-9696
Mailing Address - Fax:918-485-1701
Practice Address - Street 1:1317 S DEWEY AVE
Practice Address - Street 2:
Practice Address - City:WAGONER
Practice Address - State:OK
Practice Address - Zip Code:74467-7013
Practice Address - Country:US
Practice Address - Phone:918-485-9696
Practice Address - Fax:918-485-1701
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-07
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21712207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK600522432OtherMEDICARE GROUP PTAN
OKOK100338OtherMEDICARE PTAN
600522432Medicare PIN