1932240041 NPI number — PAIN MANAGEMENT OF TULSA P C

Table of content: (NPI 1932240041)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932240041 NPI number — PAIN MANAGEMENT OF TULSA P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PAIN MANAGEMENT OF TULSA P C
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:
1932240041
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/27/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6802 S OLYMPIA AVE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
TULSA
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74132-1823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-447-9300
Provider Business Mailing Address Fax Number:
918-447-9308

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6802 S OLYMPIA AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74132-1823
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-447-9300
Provider Business Practice Location Address Fax Number:
918-447-9308
Provider Enumeration Date:
02/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANTHONY
Authorized Official First Name:
C
Authorized Official Middle Name:
SCOTT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
918-447-9300

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  2940 , 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: DF6291 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".
  • Identifier: 200107040A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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