Basic Information
| Provider Information | |||||||||
| NPI: | 1407932981 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | URGENT MEDCARE CLINIC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4805 E HIGHWAY 37 | ||||||||
| Address2: | |||||||||
| City: | TUTTLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730898791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053819979 | ||||||||
| FaxNumber: | 4053819130 | ||||||||
| Practice Location | |||||||||
| Address1: | 4805 E HIGHWAY 37 | ||||||||
| Address2: | |||||||||
| City: | TUTTLE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730898791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053819979 | ||||||||
| FaxNumber: | 4053819130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2006 | ||||||||
| LastUpdateDate: | 05/01/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLDER | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4053819979 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
| NPICertificationDate: | |||||||||
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 | 200054600B | 05 | OK | MEDICAID | 200054600A | 05 | OK | MEDICAID | 200054600C | 05 | OK | MEDICAID |