Provider Demographics
NPI:1659371656
Name:ADULT MEDICINE SPECIALIST OF CANADIAN VALLEY, P.L.C
Entity Type:Organization
Organization Name:ADULT MEDICINE SPECIALIST OF CANADIAN VALLEY, P.L.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:
Authorized Official - Credentials:MO
Authorized Official - Phone:405-354-2118
Mailing Address - Street 1:PO BOX 851100
Mailing Address - Street 2:DEPT 200
Mailing Address - City:YUKON
Mailing Address - State:OK
Mailing Address - Zip Code:73085
Mailing Address - Country:US
Mailing Address - Phone:405-354-2118
Mailing Address - Fax:405-354-1380
Practice Address - Street 1:1608 PROFESSIONAL CIRCLE
Practice Address - Street 2:
Practice Address - City:YUKON
Practice Address - State:OK
Practice Address - Zip Code:73099
Practice Address - Country:US
Practice Address - Phone:405-354-2118
Practice Address - Fax:405-354-1380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty