1215319371 NPI number — OKLAHOMA PAIN MANAGEMENT PLLC

Table of content: (NPI 1215319371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215319371 NPI number — OKLAHOMA PAIN MANAGEMENT PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA PAIN MANAGEMENT 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:
1215319371
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 108835
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:
73101-8835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-775-9350
Provider Business Mailing Address Fax Number:
405-775-9360

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3601 NW 138TH ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
OKLAHOMA CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73134-2513
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-242-4100
Provider Business Practice Location Address Fax Number:
405-775-9356
Provider Enumeration Date:
06/25/2015

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MITCHELL
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
A
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
405-242-4100

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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