Provider Demographics
NPI:1750386223
Name:SEMINOLE MEDICAL CLINIC
Entity type:Organization
Organization Name:SEMINOLE MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MS
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BUTNER
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP
Authorized Official - Phone:405-382-4939
Mailing Address - Street 1:2403 W WRANGLER BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-1900
Mailing Address - Country:US
Mailing Address - Phone:405-382-4939
Mailing Address - Fax:405-382-4947
Practice Address - Street 1:2403 W WRANGLER BLVD
Practice Address - Street 2:STE A
Practice Address - City:SEMINOLE
Practice Address - State:OK
Practice Address - Zip Code:74868-1900
Practice Address - Country:US
Practice Address - Phone:405-382-4939
Practice Address - Fax:405-382-4947
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-20
Last Update Date:2014-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100748760AMedicaid
OK100748760AMedicaid
OK400522129Medicare PIN