Provider Demographics
NPI:1992995666
Name:ABC MEDICAL CLINIC, INC PLLC
Entity type:Organization
Organization Name:ABC MEDICAL CLINIC, INC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEINZE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:580-889-3355
Mailing Address - Street 1:PO BOX 568
Mailing Address - Street 2:
Mailing Address - City:ATOKA
Mailing Address - State:OK
Mailing Address - Zip Code:74525-0568
Mailing Address - Country:US
Mailing Address - Phone:580-889-3355
Mailing Address - Fax:580-889-5272
Practice Address - Street 1:1510 S VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:ATOKA
Practice Address - State:OK
Practice Address - Zip Code:74525-3246
Practice Address - Country:US
Practice Address - Phone:580-889-3355
Practice Address - Fax:580-927-9941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2013-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2096207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100747790CMedicaid
OK300522018Medicare PIN