Provider Demographics
NPI:1144307554
Name:MIDWAY MEDICAL CLINIC
Entity type:Organization
Organization Name:MIDWAY MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MCKINLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:BOATNER
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:405-610-3600
Mailing Address - Street 1:PO BOX 30739
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73140
Mailing Address - Country:US
Mailing Address - Phone:405-610-3600
Mailing Address - Fax:405-610-3607
Practice Address - Street 1:351 N AIR DEPOT BLVD
Practice Address - Street 2:SUITE BB
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-1700
Practice Address - Country:US
Practice Address - Phone:405-610-3600
Practice Address - Fax:405-610-3607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200015390AMedicaid
OK200015390BMedicaid
OK200015390BMedicaid
OK=========001OtherBLUE CROSS BLUE SHIELD
OK=========001OtherBLUE CROSS BLUE SHIELD