Provider Demographics
NPI:1285068791
Name:ST. MADRON MEDICAL CLINIC
Entity type:Organization
Organization Name:ST. MADRON MEDICAL CLINIC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DARREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-503-6235
Mailing Address - Street 1:303 TOWSON AVE.
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72901
Mailing Address - Country:US
Mailing Address - Phone:918-503-6235
Mailing Address - Fax:918-398-0637
Practice Address - Street 1:205 E. RAY FINE BLVD ST. 6
Practice Address - Street 2:
Practice Address - City:ROLAND
Practice Address - State:OK
Practice Address - Zip Code:74954
Practice Address - Country:US
Practice Address - Phone:918-503-6235
Practice Address - Fax:918-398-0637
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK17754174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty