Organization
GRAND LAKE REGIONAL CARDIOLOGY SERVICES LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. PAUL EDWARD CALLICOAT JR. MD (PHYSICIAN MANAGER)
(918) 786-7667
Entity
Organization
Contact information
Practice address
1001 E 18TH ST, GROVE, OK 74344-2907
(918) 786-1070
(918) 786-7699
Mailing address
PO BOX 452438, GROVE, OK 74345-2438
(918) 786-1070
(918) 786-7699
Taxonomy
Speciality
Code
Description
License number
State
207RI0011X
Interventional Cardiology Physician
Primary
—
OK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200046050A
—
OK
Enumeration date
07/20/2005
Last updated
07/21/2022
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