Provider Demographics
NPI:1780011874
Name:CROSSROADS MEDICAL MANAGEMENT PC
Entity Type:Organization
Organization Name:CROSSROADS MEDICAL MANAGEMENT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:CONAWAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-585-2030
Mailing Address - Street 1:2508 N HARRISON
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804
Mailing Address - Country:US
Mailing Address - Phone:405-585-2030
Mailing Address - Fax:405-585-0318
Practice Address - Street 1:2508 N HARRISON
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804
Practice Address - Country:US
Practice Address - Phone:405-585-2030
Practice Address - Fax:405-585-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
19091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100131940BMedicaid
F91181Medicare UPIN