Provider Demographics
NPI:1992094049
Name:DAVENPORT MEDICAL CENTER LLC
Entity type:Organization
Organization Name:DAVENPORT MEDICAL CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:
Authorized Official - Last Name:WOHLGEMUTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-249-9611
Mailing Address - Street 1:203 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:OK
Mailing Address - Zip Code:74026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:203 N BROADWAY
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:OK
Practice Address - Zip Code:74026
Practice Address - Country:US
Practice Address - Phone:405-249-9611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-29
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK242363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty