Provider Demographics
NPI:1306118377
Name:SALLISAW MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:SALLISAW MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:L
Authorized Official - Last Name:POITEVINT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-790-2890
Mailing Address - Street 1:202 E CHEROKEE AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-4600
Mailing Address - Country:US
Mailing Address - Phone:918-790-2890
Mailing Address - Fax:918-790-2906
Practice Address - Street 1:202 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-4600
Practice Address - Country:US
Practice Address - Phone:918-790-2890
Practice Address - Fax:918-790-2906
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4840207Q00000X
OKR0074165363LF0000X
OK4825207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty