Provider Demographics
NPI:1356360473
Name:SPECIALTY CLINICS OF ST ANNE PLLC
Entity type:Organization
Organization Name:SPECIALTY CLINICS OF ST ANNE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUTISTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-338-8700
Mailing Address - Street 1:350 NE 12TH ST
Mailing Address - Street 2:
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-3624
Mailing Address - Country:US
Mailing Address - Phone:580-338-8700
Mailing Address - Fax:580-338-8600
Practice Address - Street 1:350 NE 12TH ST
Practice Address - Street 2:
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-3624
Practice Address - Country:US
Practice Address - Phone:580-338-8700
Practice Address - Fax:580-338-8600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26523207Q00000X
OK19772207R00000X
OK19756207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100748490AMedicaid
OK100748490AMedicaid