Provider Demographics
NPI:1437482692
Name:GREGORY MEDICAL CLINIC LLC
Entity Type:Organization
Organization Name:GREGORY MEDICAL CLINIC LLC
Other - Org Name:DR. MYRA GREGORY DO
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MYRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GREGORY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-647-9533
Mailing Address - Street 1:2202 N BROADWAY ST
Mailing Address - Street 2:PO BOX 1368
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2000
Mailing Address - Country:US
Mailing Address - Phone:918-647-9533
Mailing Address - Fax:918-647-9492
Practice Address - Street 1:2202 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2000
Practice Address - Country:US
Practice Address - Phone:918-647-9533
Practice Address - Fax:918-647-9492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-04
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3031207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100120120FMedicaid
OKOK100377Medicare PIN
OKF28652Medicare UPIN