Provider Demographics
NPI:1467976654
Name:BLICK MEDICAL LLC
Entity Type:Organization
Organization Name:BLICK MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-339-8001
Mailing Address - Street 1:1710 W 3RD ST STE 100
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-5160
Mailing Address - Country:US
Mailing Address - Phone:580-339-8001
Mailing Address - Fax:580-339-8031
Practice Address - Street 1:1007 N MAIN ST STE 101
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-2830
Practice Address - Country:US
Practice Address - Phone:580-339-8001
Practice Address - Fax:580-339-8031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-28
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200734120AMedicaid