| Organization Name: | SOUTHCREST MEDICAL GROUP LLC |
| NPI Number: | 1992736250 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | DEBBIE BREWER (DIRECTOR OF PROVIDER ENROLLMENT) |
| Mailing Address: | 6528 E 101st St Ste I Tulsa |
| State: | OK US |
| Postal Code: | 741336724 |
| Phone Number: | 9182944803 |
| Fax Number: | |
| NPI Enumeration Date: | 07/05/2006 |
| NPI Last Update Date: | 04/20/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |