Provider Demographics
NPI:1770178170
Name:SHAWNEE MEDICAL CENTER CLINIC, INC
Entity type:Organization
Organization Name:SHAWNEE MEDICAL CENTER CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-272-7452
Mailing Address - Street 1:1102 W MACARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-1743
Mailing Address - Country:US
Mailing Address - Phone:405-272-7311
Mailing Address - Fax:405-272-6962
Practice Address - Street 1:1102 W MACARTHUR ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-1743
Practice Address - Country:US
Practice Address - Phone:405-272-7311
Practice Address - Fax:405-272-6962
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSM HEALTH CARE OF OKLAHOMA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-08
Last Update Date:2021-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Multi-Specialty
No2471R0002XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiation TherapyGroup - Multi-Specialty