Provider Demographics
NPI:1649453689
Name:IRVIN MEDICAL CLINIC PLLC
Entity type:Organization
Organization Name:IRVIN MEDICAL CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:IRVIN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-317-9000
Mailing Address - Street 1:1001 E JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:HUGO
Mailing Address - State:OK
Mailing Address - Zip Code:74743-4225
Mailing Address - Country:US
Mailing Address - Phone:580-317-9000
Mailing Address - Fax:580-317-9024
Practice Address - Street 1:1001 E JACKSON ST
Practice Address - Street 2:
Practice Address - City:HUGO
Practice Address - State:OK
Practice Address - Zip Code:74743-4225
Practice Address - Country:US
Practice Address - Phone:580-317-9000
Practice Address - Fax:580-317-9024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-13
Last Update Date:2008-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3636207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty