Provider Demographics
NPI:1811073158
Name:INTERNAL MEDICINE ASSOCIATES OF PONCA CITY PLLC
Entity type:Organization
Organization Name:INTERNAL MEDICINE ASSOCIATES OF PONCA CITY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:R
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:5807-616-1778
Mailing Address - Street 1:100 ELMWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-3406
Mailing Address - Country:US
Mailing Address - Phone:580-716-1778
Mailing Address - Fax:580-382-4157
Practice Address - Street 1:100 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-3406
Practice Address - Country:US
Practice Address - Phone:580-716-1778
Practice Address - Fax:580-382-4157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-30
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3741207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200037370AMedicaid
H30873Medicare UPIN
OK200037370AMedicaid