Provider Demographics
NPI:1962510032
Name:SOUTHWARD FAMILY MEDICINE
Entity Type:Organization
Organization Name:SOUTHWARD FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:
Authorized Official - Last Name:SOUTHWARD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-223-9008
Mailing Address - Street 1:1111 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2354
Mailing Address - Country:US
Mailing Address - Phone:580-223-9008
Mailing Address - Fax:580-223-5051
Practice Address - Street 1:1111 WALNUT DR
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2354
Practice Address - Country:US
Practice Address - Phone:580-223-9008
Practice Address - Fax:580-223-9114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21988261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK442785229-001Medicaid
OK442785229-001Medicaid
OK241323211Medicare PIN