Provider Demographics
NPI:1578174074
Name:GENESIS MEDICAL PLLC
Entity Type:Organization
Organization Name:GENESIS MEDICAL PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING/CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:SHERRY
Authorized Official - Middle Name:LYNNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-223-5180
Mailing Address - Street 1:2002 12TH AVE NW STE B
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-1206
Mailing Address - Country:US
Mailing Address - Phone:580-221-2022
Mailing Address - Fax:580-221-2024
Practice Address - Street 1:2002 12TH AVE NW STE B
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-1206
Practice Address - Country:US
Practice Address - Phone:580-221-2022
Practice Address - Fax:580-221-2024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-10
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty