Provider Demographics
NPI:1407966575
Name:FAMILY MEDICINE SPECIALISTS, P.C.
Entity Type:Organization
Organization Name:FAMILY MEDICINE SPECIALISTS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:FERRELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-273-6383
Mailing Address - Street 1:3700 N KICKAPOO AVE
Mailing Address - Street 2:SUITE 124
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1707
Mailing Address - Country:US
Mailing Address - Phone:405-273-6383
Mailing Address - Fax:405-214-1075
Practice Address - Street 1:3700 N KICKAPOO AVE
Practice Address - Street 2:SUITE 124
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1707
Practice Address - Country:US
Practice Address - Phone:405-273-6383
Practice Address - Fax:405-214-1075
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2011-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100745230CMedicaid
OK1147540001Medicare NSC
OK=========Medicare ID - Type UnspecifiedMEDICARE
OK100745230CMedicaid