Provider Demographics
NPI:1972005981
Name:STILLWATER MEDICAL CENTER AUTHORITY
Entity Type:Organization
Organization Name:STILLWATER MEDICAL CENTER AUTHORITY
Other - Org Name:COMMUNITY MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:ADRIENNE
Authorized Official - Last Name:WEBBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-742-5230
Mailing Address - Street 1:PO BOX 720006
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4006
Mailing Address - Country:US
Mailing Address - Phone:405-533-6057
Mailing Address - Fax:
Practice Address - Street 1:1318 ELM ST
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:OK
Practice Address - Zip Code:73077-5034
Practice Address - Country:US
Practice Address - Phone:580-336-9411
Practice Address - Fax:580-336-9422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-06
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK207R00000X
261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty