Provider Demographics
NPI:1659568301
Name:CMG FAMILY CLINIC LLC
Entity Type:Organization
Organization Name:CMG FAMILY CLINIC LLC
Other - Org Name:ENLOW FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWARER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-1234
Mailing Address - Street 1:1203 E ROSS BYP
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4133
Mailing Address - Country:US
Mailing Address - Phone:918-453-1234
Mailing Address - Fax:918-453-9107
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4133
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:918-453-9107
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMG FAMILY CLINIC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-09-26
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0067005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK600522432OtherMEDICARE GROUP NUMBER