Basic Information
| Provider Information | |||||||||
| NPI: | 1235121096 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORMAN CLINIC INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N PORTER AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053290121 | ||||||||
| FaxNumber: | 4052926099 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 N PORTER AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053290121 | ||||||||
| FaxNumber: | 4052926099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2005 | ||||||||
| LastUpdateDate: | 04/03/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MERRILL | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN ADMIN. | ||||||||
| AuthorizedOfficialTelephone: | 4053290121 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0011X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207Q00000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2084N0400X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 207RC0000X | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207R00000X | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14455 | 01 | OK | WEBMD | OTHER | 100738950A | 05 | OK | MEDICAID |