Provider Demographics
NPI:1760720668
Name:STILLWATER HISTOLOGY LLC
Entity Type:Organization
Organization Name:STILLWATER HISTOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:SWAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-372-2390
Mailing Address - Street 1:1301 W. 6TH ST
Mailing Address - Street 2:SUITE 106
Mailing Address - City:STILLWATER
Mailing Address - State:OK
Mailing Address - Zip Code:74074
Mailing Address - Country:US
Mailing Address - Phone:405-372-2390
Mailing Address - Fax:405-742-5706
Practice Address - Street 1:1301 W. 6TH ST
Practice Address - Street 2:SUITE 106
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74074
Practice Address - Country:US
Practice Address - Phone:405-372-2390
Practice Address - Fax:405-742-5706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207RG0100X, 261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty