Provider Demographics
NPI:1902864689
Name:OGE FAMILY MEDICAL CLINIC
Entity Type:Organization
Organization Name:OGE FAMILY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:T
Authorized Official - Last Name:OGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-451-9199
Mailing Address - Street 1:PO BOX 905
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:71852-0905
Mailing Address - Country:US
Mailing Address - Phone:870-451-9199
Mailing Address - Fax:870-451-9442
Practice Address - Street 1:410 N MAIN ST
Practice Address - Street 2:SUITE 2
Practice Address - City:NASHVILLE
Practice Address - State:AR
Practice Address - Zip Code:71852-2006
Practice Address - Country:US
Practice Address - Phone:870-451-9199
Practice Address - Fax:870-451-9442
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-03
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR154132002Medicaid
AR770304202OtherBREASTCARE
AR5F105OtherBCBS
AR5F105Medicare PIN