Provider Demographics
NPI:1790398360
Name:ANDERSON FAMILY MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:ANDERSON FAMILY MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, APRN-CNP
Authorized Official - Phone:918-564-2726
Mailing Address - Street 1:2505 N BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953-2050
Mailing Address - Country:US
Mailing Address - Phone:918-564-2726
Mailing Address - Fax:918-564-2732
Practice Address - Street 1:2505 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-2050
Practice Address - Country:US
Practice Address - Phone:918-564-2726
Practice Address - Fax:918-564-2732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2022-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200571200AMedicaid