Basic Information
| Provider Information | |||||||||
| NPI: | 1134308968 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL SPECIALISTS OF OKLAHOMA PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 7570 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730837570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058424850 | ||||||||
| FaxNumber: | 4052422180 | ||||||||
| Practice Location | |||||||||
| Address1: | 9817 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731392812 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056324500 | ||||||||
| FaxNumber: | 4056327500 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/29/2007 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COSBY | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR/BOARD | ||||||||
| AuthorizedOfficialTelephone: | 4058424850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SURGICAL SPECIALISTS OF OKLAHOMA PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 1013950740 | 01 | OK | NPI | OTHER |