| Main Street Family Healthcare Nurse Practitioner Clinic, Llc | |
|
309 W Main St Stroud OK 74079-3611 | |
| (918) 987-0067 | |
| Not Available |
| Full Name | Main Street Family Healthcare Nurse Practitioner Clinic, Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 309 W Main St, Stroud, Oklahoma |
| Authorized Official Name and Position | Bronwyn L. Howard (OWNER/OPERATOR) |
| Authorized Official Contact | 9189505053 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Main Street Family Healthcare Nurse Practitioner Clinic, Llc 309 W Main St P.o. Box 968 Stroud OK 74079-3611 Ph: (918) 987-0067 | Main Street Family Healthcare Nurse Practitioner Clinic, Llc 309 W Main St Stroud OK 74079-3611 Ph: (918) 987-0067 |
| NPI Number | 1154719169 |
|---|---|
| Provider Enumeration Date | 12/27/2014 |
| Last Update Date | 12/18/2015 |
| Medicare PECOS PAC ID | 4183924855 |
|---|---|
| Medicare Enrollment ID | O20151202000696 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1154719169 | NPI | - | NPPES |
| 200121770A | Medicaid | OK | |
| 2005513360A | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QP2300X | Clinic/center - Primary Care | R0052024 (Oklahoma) | Primary |
| Provider Name | Sandra K Dimmitt |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1245264894 PECOS PAC ID: 1951388990 Enrollment ID: I20040923000751 |
| Provider Name | Bronwyn L Howard |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1619161205 PECOS PAC ID: 7214027747 Enrollment ID: I20071220000144 |
| Provider Name | Peggy Moore Gardner |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1427463082 PECOS PAC ID: 7517289127 Enrollment ID: I20141210002027 |
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