Basic Information
| Provider Information | |||||||||
| NPI: | 1134376445 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SURGICAL SPECIALISTS OF OKLAHOMA, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7570 | ||||||||
| Address2: | |||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730837570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058424850 | ||||||||
| FaxNumber: | 4052422180 | ||||||||
| Practice Location | |||||||||
| Address1: | 3705 NW 63RD ST | ||||||||
| Address2: | STE. 204 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731161935 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4059427841 | ||||||||
| FaxNumber: | 4056084239 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2008 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
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| AuthorizedOfficialLastName: | COSBY | ||||||||
| AuthorizedOfficialFirstName: | ANGELA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4058424850 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SURGICAL SPECIALISTS OF OKLAHOMA, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | 1275508186 | 01 | OK | NPI | OTHER | 1043286776 | 01 | OK | NPI | OTHER |