BROKEN ARROW FAMILY CLINIC INC

Provider Demographics

• NPI: 1497966303
• Name: BROKEN ARROW FAMILY CLINIC INC
• Entity Type: Organization
• Organization Name: BROKEN ARROW FAMILY CLINIC INC
• Authorized Official - Title/Position: PRESIDENT
• Authorized Official - First Name: BRIAN
• Authorized Official - Last Name: CODER
• Authorized Official - Phone: 918-251-2666
• Mailing Address - Street 1: 705 W OAKLAND ST
• Mailing Address - City: BROKEN ARROW
• Mailing Address - State: OK
• Mailing Address - Zip Code: 74012-1656
• Mailing Address - Country: US
• Mailing Address - Phone: 918-251-2666
• Mailing Address - Fax: 918-258-7790
• Practice Address - Street 1: 705 W OAKLAND ST
• Practice Address - City: BROKEN ARROW
• Practice Address - State: OK
• Practice Address - Zip Code: 74012-1656
• Practice Address - Country: US
• Practice Address - Phone: 918-251-2666
• Practice Address - Fax: 918-258-7790
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-05-24
• Last Update Date: 2023-05-16

Provider Licenses

State	License ID	Taxonomies
OK	1577	207Q00000X
OK	1530	207Q00000X
OK	1827	207Q00000X
OK	3252	207Q00000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	207Q00000X	Allopathic & Osteopathic Physicians	Family Medicine		Group - Single Specialty

Provider Identifiers

State	Identifier ID	ID Type	Issuer
OK	100090910A	Medicaid
OK	100258080A	Medicaid
OK	100177740A	Medicaid
OK	100183270A	Medicaid
OK	100257900A	Medicaid
OK	1427164888	Other	BRIAN CODER NPI
OK	1679502173	Other	ARTHUR CODER NPI
OK	1811923949	Other	JAMES CODER NPI
OK	100090910B	Medicaid
OK	100178470A	Medicaid
OK	1001257870A	Medicaid
OK	1447234885	Other	CAROLE HOWARD NPI
OK	100090910A	Medicaid
OK	E45398	Medicare UPIN
OK	100178470A	Medicaid
OK	486521601M	Medicare ID - Type Unspecified	ARTHUR CODER
OK	487561005M	Medicare ID - Type Unspecified	CAROLE HOWARD
OK	100177740A	Medicaid
OK	100257900A	Medicaid
OK	100183270A	Medicaid