Provider Demographics
NPI:1578174983
Name:SAINT MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:SAINT MEDICAL GROUP, LLC
Other - Org Name:SSM HEALTH MEDICAL GROUP AT CHESAPEAKE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PROVIDER ENROLLMENT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-272-7452
Mailing Address - Street 1:2749 PROGRESSIVE DR
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73034-7649
Mailing Address - Country:US
Mailing Address - Phone:405-772-4130
Mailing Address - Fax:405-772-4135
Practice Address - Street 1:2749 PROGRESSIVE DR
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034-7649
Practice Address - Country:US
Practice Address - Phone:405-772-4130
Practice Address - Fax:405-772-4135
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH CARE OF OKLAHOMA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-08-11
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty