Provider Demographics
NPI:1053380287
Name:CARDIOLOGY CLINIC OF MUSKOGEE, INC.
Entity type:Organization
Organization Name:CARDIOLOGY CLINIC OF MUSKOGEE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:ANN
Authorized Official - Middle Name:BARKER
Authorized Official - Last Name:ONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-683-0753
Mailing Address - Street 1:350 S 40TH ST
Mailing Address - Street 2:CCOM MEDICAL GROUP
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4915
Mailing Address - Country:US
Mailing Address - Phone:918-683-0753
Mailing Address - Fax:
Practice Address - Street 1:350 S 40TH ST
Practice Address - Street 2:CCOM MEDICAL GROUP
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4915
Practice Address - Country:US
Practice Address - Phone:918-683-0753
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100734500AMedicaid
OK100734500AMedicaid