Provider Demographics
NPI:1508096447
Name:TISHOMINGO DOCTOR'S MEDICAL CLINIC, PC
Entity Type:Organization
Organization Name:TISHOMINGO DOCTOR'S MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:VIRGINIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-371-9117
Mailing Address - Street 1:508 E 24TH ST
Mailing Address - Street 2:
Mailing Address - City:TISHOMINGO
Mailing Address - State:OK
Mailing Address - Zip Code:73460-3214
Mailing Address - Country:US
Mailing Address - Phone:580-371-9117
Mailing Address - Fax:580-371-3170
Practice Address - Street 1:508 E 24TH ST
Practice Address - Street 2:
Practice Address - City:TISHOMINGO
Practice Address - State:OK
Practice Address - Zip Code:73460-3214
Practice Address - Country:US
Practice Address - Phone:580-371-9117
Practice Address - Fax:580-371-3170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-24
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty