Provider Demographics
NPI:1407879729
Name:OB-GYN CARE OF NORTHWEST OKLAHOMA
Entity Type:Organization
Organization Name:OB-GYN CARE OF NORTHWEST OKLAHOMA
Other - Org Name:A CARING PLACE FOR WOMEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:MARVIN
Authorized Official - Last Name:WAGNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-256-6000
Mailing Address - Street 1:1024 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-3120
Mailing Address - Country:US
Mailing Address - Phone:580-256-6000
Mailing Address - Fax:580-256-6008
Practice Address - Street 1:1024 MAIN ST
Practice Address - Street 2:
Practice Address - City:WOODWARD
Practice Address - State:OK
Practice Address - Zip Code:73801-3120
Practice Address - Country:US
Practice Address - Phone:580-256-6000
Practice Address - Fax:580-256-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-26
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK24684174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200073250AMedicaid
OK278469022001OtherBLUE CROSS
OK200073250AMedicaid
OK500522128Medicare ID - Type Unspecified