Provider Demographics
NPI:1861034779
Name:SHAWNEE MEDICAL CENTER CLINIC, INC.
Entity Type:Organization
Organization Name:SHAWNEE MEDICAL CENTER CLINIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT/INS CREDENTIAL
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-272-7452
Mailing Address - Street 1:2403 W WRANGLER BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-1900
Mailing Address - Country:US
Mailing Address - Phone:405-716-3070
Mailing Address - Fax:405-716-3069
Practice Address - Street 1:2403 W WRANGLER BLVD STE C
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-1900
Practice Address - Country:US
Practice Address - Phone:405-716-3070
Practice Address - Fax:405-716-3069
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH CARE OF OKLAHOMA, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty