Provider Demographics
NPI:1023240538
Name:OKLAHOMA SPINE SURGERY & ORTHOPEDICS
Entity type:Organization
Organization Name:OKLAHOMA SPINE SURGERY & ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:D
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-703-4905
Mailing Address - Street 1:3110 SW 89TH ST
Mailing Address - Street 2:102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73159-7920
Mailing Address - Country:US
Mailing Address - Phone:405-703-4905
Mailing Address - Fax:405-703-4980
Practice Address - Street 1:3110 SW 89TH ST
Practice Address - Street 2:102
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-7920
Practice Address - Country:US
Practice Address - Phone:405-703-4905
Practice Address - Fax:405-703-4980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-17
Last Update Date:2009-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21476207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty