Provider Demographics
NPI:1629507918
Name:FAMILY CARE CLINIC INC
Entity Type:Organization
Organization Name:FAMILY CARE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-776-0050
Mailing Address - Street 1:1506 W CHICKASAW AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-7200
Mailing Address - Country:US
Mailing Address - Phone:918-776-0050
Mailing Address - Fax:918-776-0065
Practice Address - Street 1:1506 W CHICKASAW AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-7200
Practice Address - Country:US
Practice Address - Phone:918-776-0050
Practice Address - Fax:918-776-0065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27009208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200245750Medicaid