Provider Demographics
NPI:1821052473
Name:GEMINI MEDICAL GROUP INC
Entity Type:Organization
Organization Name:GEMINI MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:GAYLE
Authorized Official - Middle Name:
Authorized Official - Last Name:BURDEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-331-1090
Mailing Address - Street 1:226 SE DEBELL AVE BLDG A
Mailing Address - Street 2:
Mailing Address - City:BARTLESVILLE
Mailing Address - State:OK
Mailing Address - Zip Code:74006-2343
Mailing Address - Country:US
Mailing Address - Phone:918-331-1090
Mailing Address - Fax:918-331-1091
Practice Address - Street 1:226 SE DEBELL AVE
Practice Address - Street 2:
Practice Address - City:BARTLESVILLE
Practice Address - State:OK
Practice Address - Zip Code:74006-2343
Practice Address - Country:US
Practice Address - Phone:918-331-1090
Practice Address - Fax:918-331-1091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-12
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherMEDICARE PTAN
OK5593470002Medicare NSC
OK=========OtherMEDICARE PTAN
OK5593470003Medicare NSC