Provider Demographics
NPI:1538109319
Name:FALLINGWATER MEDICAL ASSOCIATES, PLLC
Entity Type:Organization
Organization Name:FALLINGWATER MEDICAL ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:FRANCIS
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:MCGOURAN
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:580-255-8564
Mailing Address - Street 1:1334 N HARVILLE RD
Mailing Address - Street 2:
Mailing Address - City:DUNCAN
Mailing Address - State:OK
Mailing Address - Zip Code:73533-1514
Mailing Address - Country:US
Mailing Address - Phone:580-255-8564
Mailing Address - Fax:580-255-8640
Practice Address - Street 1:1334 N HARVILLE RD
Practice Address - Street 2:
Practice Address - City:DUNCAN
Practice Address - State:OK
Practice Address - Zip Code:73533-1514
Practice Address - Country:US
Practice Address - Phone:580-255-8564
Practice Address - Fax:580-255-8640
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-08
Last Update Date:2015-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100058840FMedicaid
OKE57396Medicare UPIN
OK100058840FMedicaid