Provider Demographics
NPI:1932591419
Name:SITESOURCE MEDICAL, LLC
Entity Type:Organization
Organization Name:SITESOURCE MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARIE
Authorized Official - Middle Name:
Authorized Official - Last Name:BAILEY
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-748-0122
Mailing Address - Street 1:PO BOX 18622
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73154-0622
Mailing Address - Country:US
Mailing Address - Phone:405-748-0122
Mailing Address - Fax:
Practice Address - Street 1:324 N ROBINSON AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73102-6416
Practice Address - Country:US
Practice Address - Phone:405-748-0122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-20
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty