Broken Arrow Diagnostic Medicine, PLLC
Organization Active NPI Family Medicine Physician · Broken Arrow, OK
NPI 1710322672 · NPPES record last updated Oct 8, 2024
Key facts
- NPI
- 1710322672
- Entity type
- Organization (NPI type 2)
- Primary specialty
- Family Medicine Physician 207Q00000X
- Legal business name
- BROKEN ARROW DIAGNOSTIC MEDICINE, PLLC
- Practice address
- 5050 E Kenosha St
Broken Arrow, OK 74014-6711 - Phone
- (918) 994-5140
- Fax
- (918) 994-5150
- NPI assigned
- May 6, 2013
- Organization subpart
- No
Authorized official
- Name
- Jacob Leon Callison, PA
- Title
- Managing Member
- Phone
- (918) 994-5140
Practitioners 3
Laboratory certificates & supplier records
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 37D2058894 | Broken Arrow Diagnostic Medicine | Certificate of waiver | May 13, 2027 |
National Provider Directory
Locations
123 N Main St
Broken Arrow, OK 74012
Phone (918) 994-5140
110 N 1st St
Broken Arrow, OK 74012
Phone (918) 258-1547
Interoperability endpoints
- https://api.platform.athenahealth.com/7102/brand/2/csg/1/fhir/r4
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician |
207Q00000X | OK | Yes |
Addresses
Primary practice location
5050 E Kenosha St
Broken Arrow, OK 74014-6711
Mailing address
5050 E Kenosha St
Broken Arrow, OK 74014-6711
Phone (918) 994-5140
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 200520620A | Medicaid | OK | |
| 1700851052 | Other | OK | NPI |
| 1487885877 | Other | OK | NPI |
Other providers in Broken Arrow, OK
- Stephani Brooke Brisbin
- Merle Gene Brock
- Broken Arrow Bone and Joint Specialists, PC
- Broken Arrow Counseling Services LLC
- Broken Arrow Dental and Implants, LLC
- Broken Arrow Endodontics
- Broken Arrow Family Clinic Inc
- Broken Arrow Family Dentistry PLLC
- Broken Arrow Family Practice Center
- Broken Arrow Family Practice Center PLC
All providers in Broken Arrow, OK · Family Medicine Physician in Oklahoma
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Oct 8, 2024. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.