1518443761 NPI number — FOOT & ANKLE SURGEONS OF OKLAHOMA PLLC

Table of content: (NPI 1518443761)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518443761 NPI number — FOOT & ANKLE SURGEONS OF OKLAHOMA PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT & ANKLE SURGEONS OF OKLAHOMA 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:
1518443761
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 268996
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:
73126-8996
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
405-418-4500
Provider Business Mailing Address Fax Number:
405-418-4501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1703 PROFESSIONAL CIR STE 101
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YUKON
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73099-6497
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
405-418-4500
Provider Business Practice Location Address Fax Number:
405-418-4501
Provider Enumeration Date:
07/11/2018

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
405-418-4505

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200434410A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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