Basic Information
| Provider Information | |||||||||
| NPI: | 1134314388 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FIRSTCARE MEDICAL CLINIC OF MUSKOGEE PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3300 CHANDLER RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744034957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186813333 | ||||||||
| FaxNumber: | 9186813336 | ||||||||
| Practice Location | |||||||||
| Address1: | 3300 CHANDLER RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744034957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186813333 | ||||||||
| FaxNumber: | 9186813336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/11/2007 | ||||||||
| LastUpdateDate: | 10/27/2010 | ||||||||
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| AuthorizedOfficialLastName: | ROBISON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9186838100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 446187037001 | 01 | BCBS OF OKLAHOMA | OTHER | P00011976 | 01 | RAILROAD MEDICARE | OTHER |