Provider Demographics
NPI:1437211406
Name:SHOCKEY INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:SHOCKEY INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:SHOCKEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-223-6767
Mailing Address - Street 1:2419 CHICKASAW BLVD
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1466
Mailing Address - Country:US
Mailing Address - Phone:580-223-6767
Mailing Address - Fax:580-224-0275
Practice Address - Street 1:2419 CHICKASAW BLVD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1466
Practice Address - Country:US
Practice Address - Phone:580-223-6767
Practice Address - Fax:580-224-0275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18264207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100202500AMedicaid
OK100202500AMedicaid
OK800522353Medicare ID - Type Unspecified
OK800522353Medicare PIN