NPIMap

Organization Active NPI

Blackhawk Mangum, LLC

  • Family Medicine Physician
  • Mangum, OK
National Provider Identifier
1093986937
Registry record updated Jul 23, 2008
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
2208 Issued in OK
Legal business name
BLACKHAWK MANGUM, LLC
Practice address
One Wickersham Dr
Mangum, OK 73554
Phone
(580) 782-3353
Fax
(580) 782-2811
NPI assigned
Mar 19, 2008
Last updated
Jul 23, 2008By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jul 23, 2008

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Shana Davenport
Title
Insurance Credentialing Supervisor
Phone
(512) 681-3460

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X 2208 OK
Family Nurse Practitioner 363LF0000X 2208 OK
Emergency Medicine Physician 207P00000X 2208 OK
Family Medicine Physician 207Q00000X 2208 OK Primary

Addresses

Primary practice location

One Wickersham Dr
Mangum, OK 73554

Mailing address

PO Box 280
Mangum, OK 73554

National Provider Directory

National Provider Directory
Tax ID family
Blackhawk Mangum LLC10 organizations share this tax ID, including this one

Other organizations with this tax ID 9

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1205884800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1216771200000",
    "number": "1093986937",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 280",
            "city": "MANGUM",
            "state": "OK",
            "postal_code": "73554"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "ONE WICKERSHAM DR",
            "city": "MANGUM",
            "state": "OK",
            "postal_code": "73554",
            "telephone_number": "580-782-3353",
            "fax_number": "580-782-2811"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "BLACKHAWK MANGUM, LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-03-19",
        "last_updated": "2008-07-23",
        "status": "A",
        "authorized_official_last_name": "DAVENPORT",
        "authorized_official_first_name": "SHANA",
        "authorized_official_title_or_position": "INSURANCE CREDENTIALING SUPERVISOR",
        "authorized_official_telephone_number": "512-681-3460"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "OK",
            "license": "2208",
            "primary": false
        },
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "OK",
            "license": "2208",
            "primary": false
        },
        {
            "code": "207P00000X",
            "taxonomy_group": "",
            "desc": "Emergency Medicine",
            "state": "OK",
            "license": "2208",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "OK",
            "license": "2208",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mangum, OK

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 23, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.