Provider Demographics
NPI:1770845729
Name:SAINTS MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:SAINTS MEDICAL GROUP LLC
Other - Org Name:SAINTS DERMATOLOGY NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:INSURANCE CREDENTIALING SPECIALIST
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 1:13128 N MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73142-3017
Mailing Address - Country:US
Mailing Address - Phone:405-272-7044
Mailing Address - Fax:405-272-7049
Practice Address - Street 1:13128 N MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73142-3017
Practice Address - Country:US
Practice Address - Phone:405-272-7044
Practice Address - Fax:405-272-7049
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTHCARE OF OK, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-14
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26344207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty