# CMG FAMILY CLINIC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1386817872
- **Authorized official:** LISA A SWARER (OPERATIONS MANAGER)
- **Authorized official phone:** (918) 453-1234

## Contact information

- **Practice address:** 1317 S DEWEY AVE, WAGONER, OK 74467-7013
- **Practice address phone:** (918) 485-9696
- **Practice address fax:** (918) 485-1701
- **Mailing address:** 1317 S DEWEY AVE, WAGONER, OK 74467-7013
- **Mailing address phone:** (918) 485-9696
- **Mailing address fax:** (918) 485-1701

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207Q00000X | Family Medicine Physician | 21712 | OK | Yes |

## Other

- **Enumeration date:** 04/07/2008
- **Last updated:** 05/14/2008

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 600522432 | MEDICARE GROUP PTAN | OK |
| 01 | — | OK100338 | MEDICARE PTAN | OK |