Provider Demographics
NPI:1740330596
Name:GENERAL PRACTICE MEDICAL CLINIC, INC.
Entity type:Organization
Organization Name:GENERAL PRACTICE MEDICAL CLINIC, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOBBY
Authorized Official - Middle Name:NEAL
Authorized Official - Last Name:DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-207-1400
Mailing Address - Street 1:6767 S YALE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3302
Mailing Address - Country:US
Mailing Address - Phone:918-207-1400
Mailing Address - Fax:918-207-1401
Practice Address - Street 1:1012 SOUTH PLAZA
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-207-1400
Practice Address - Fax:918-207-1401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2008-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKOK1843261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherFEIN
OK=========OtherFEIN