| Canyon Park Medical Group, Pllc | |
|
1501 E 19th St Edmond OK 73013-6618 | |
| (405) 348-6611 | |
| (405) 348-9280 |
| Full Name | Canyon Park Medical Group, Pllc |
|---|---|
| Speciality | Clinic/center - Primary Care |
| Location | 1501 E 19th St, Edmond, Oklahoma |
| Authorized Official Name and Position | Tonya Lynn Keith (CLINIC MANAGER) |
| Authorized Official Contact | 4053486611 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Canyon Park Medical Group, Pllc 1501 E 19th St Edmond OK 73013-6618 Ph: (405) 348-6611 | Canyon Park Medical Group, Pllc 1501 E 19th St Edmond OK 73013-6618 Ph: (405) 348-6611 |
| NPI Number | 1063525954 |
|---|---|
| Provider Enumeration Date | 08/16/2006 |
| Last Update Date | 05/02/2011 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1063525954 | NPI | - | NPPES |
| 37DO469469 | Other | OK | CLIA # |
| CH5055 | Other | OK | RAILROAD MEDICARE # |
| 100748060A | Medicaid | OK | |
| 4589400001 | Other | OK | DMERC GROUP # |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | 8699 (Oklahoma) | Primary |
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