Organization
CANYON PARK MEDICAL GROUP, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TONYA LYNN KEITH (CLINIC MANAGER)
(405) 348-6611
Entity
Organization
Contact information
Practice address
1501 E 19TH ST, EDMOND, OK 73013-6618
(405) 348-6611
(405) 348-9280
Mailing address
1501 E 19TH ST, EDMOND, OK 73013-6618
(405) 348-6611
(405) 348-9280
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
8699
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
100748060A
—
OK
01
—
37DO469469
CLIA #
OK
01
—
4589400001
DMERC GROUP #
OK
01
—
CH5055
RAILROAD MEDICARE #
OK
Enumeration date
08/16/2006
Last updated
05/02/2011
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