Provider Demographics
NPI:1508842444
Name:MIDWEST MEDICAL GROUP PLLC
Entity Type:Organization
Organization Name:MIDWEST MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-739-6840
Mailing Address - Street 1:1201 S DOUGLAS BLVD
Mailing Address - Street 2:SUITE J
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73130-5239
Mailing Address - Country:US
Mailing Address - Phone:405-739-6840
Mailing Address - Fax:405-732-7149
Practice Address - Street 1:1201 S DOUGLAS BLVD
Practice Address - Street 2:SUITE J
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73130-5239
Practice Address - Country:US
Practice Address - Phone:405-739-6840
Practice Address - Fax:405-732-7149
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2014-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700490BMedicaid
OK375659300OtherDEPT OF LABOR FECA
OK100700490BMedicaid
OK375659300OtherDEPT OF LABOR FECA
OK4562630001Medicare NSC