Provider Demographics
NPI:1790893097
Name:UNIVERSITY OF OKLAHOMA HEALTH SCIEN CTR SOUTHWEST OK FAMILY PRACTICE
Entity Type:Organization
Organization Name:UNIVERSITY OF OKLAHOMA HEALTH SCIEN CTR SOUTHWEST OK FAMILY PRACTICE
Other - Org Name:SOUTHWEST OKLAHOMA FAMILY PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-271-3932
Mailing Address - Street 1:1202 NW ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-6537
Mailing Address - Country:US
Mailing Address - Phone:580-248-2288
Mailing Address - Fax:580-248-5757
Practice Address - Street 1:1202 NW ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-6537
Practice Address - Country:US
Practice Address - Phone:580-248-2288
Practice Address - Fax:580-248-5757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-27
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200021490CMedicaid
OK500522074Medicare PIN