Provider Demographics
NPI:1669634168
Name:SOUTER FAMILY MEDICINE
Entity type:Organization
Organization Name:SOUTER FAMILY MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:PHILLIP
Authorized Official - Last Name:SOUTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-762-7515
Mailing Address - Street 1:1908 N 14TH ST
Mailing Address - Street 2:STE. 204
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-2014
Mailing Address - Country:US
Mailing Address - Phone:580-762-7515
Mailing Address - Fax:580-762-7373
Practice Address - Street 1:1908 N 14TH ST
Practice Address - Street 2:STE. 204
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-2014
Practice Address - Country:US
Practice Address - Phone:580-762-7515
Practice Address - Fax:580-762-7373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100034000CMedicaid
OK100034000CMedicaid