Provider Demographics
NPI:1174767933
Name:MERIDIAN CLINIC, INC
Entity type:Organization
Organization Name:MERIDIAN CLINIC, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:QUOC
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:405-943-9820
Mailing Address - Street 1:2201 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-2629
Mailing Address - Country:US
Mailing Address - Phone:405-943-9820
Mailing Address - Fax:405-947-6908
Practice Address - Street 1:2201 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-2629
Practice Address - Country:US
Practice Address - Phone:405-943-9820
Practice Address - Fax:405-947-6908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPOD209213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100780320AMedicaid
OK100780320BMedicaid
OK6319270001OtherCIGNA GOVERNMENT
OK6319270001OtherCIGNA GOVERNMENT
OK=========Medicare PIN
=========Medicare PIN
OK445769340Medicare PIN
OK6319270001Medicare PIN
OK100780320AMedicaid
6319270001Medicare NSC