1477829554 NPI number — MEDICAL CENTER PAIN CLINIC, PLLC

Table of content: (NPI 1477829554)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477829554 NPI number — MEDICAL CENTER PAIN CLINIC, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MEDICAL CENTER PAIN CLINIC, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477829554
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2700 NE 63RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73111-8305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-271-5859
Provider Business Mailing Address Fax Number:
405-232-8808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1226 N SHARTEL AVE
Provider Second Line Business Practice Location Address:
SUITE 300
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73103
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-232-8003
Provider Business Practice Location Address Fax Number:
405-232-8808
Provider Enumeration Date:
03/22/2012

Additional Information

Authorized Official

Authorized Official Last Name:
ELLIS
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
PAUL
Authorized Official Title or Position:
REGISTERED AGENT
Authorized Official Telephone Number:
405-232-8003

Provider Taxonomy Codes

  • Taxonomy code: 261QP3300X , with the licence number:  15874 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200432890A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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