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1908 N 14th St Ste. 204 Ponca City OK 74601-2014 | |
| (580) 762-7515 | |
| (580) 762-7373 |
| Full Name | |
|---|---|
| Speciality | Family Medicine |
| Location | 1908 N 14th St, Ponca City, Oklahoma |
| Authorized Official Name and Position | Michael Phillip Souter (OWNER) |
| Authorized Official Contact | 5807627515 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1908 N 14th St Ste. 204 Ponca City OK 74601-2014 Ph: (580) 762-7515 | 1908 N 14th St Ste. 204 Ponca City OK 74601-2014 Ph: (580) 762-7515 |
| NPI Number | 1669634168 |
|---|---|
| Provider Enumeration Date | 06/26/2008 |
| Last Update Date | 06/26/2008 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1669634168 | NPI | - | NPPES |
| 100034000C | Medicaid | OK |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | 3906 (Oklahoma) | Primary |
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