Provider Demographics
NPI:1851400659
Name:ACACIA MEDICAL GROUP
Entity Type:Organization
Organization Name:ACACIA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITEHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-258-2641
Mailing Address - Street 1:2010 W HOUSTON ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-8303
Mailing Address - Country:US
Mailing Address - Phone:918-258-2641
Mailing Address - Fax:918-259-1905
Practice Address - Street 1:2010 W HOUSTON ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-8303
Practice Address - Country:US
Practice Address - Phone:918-258-2641
Practice Address - Fax:918-259-1905
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069800AMedicaid