Basic Information
| Provider Information | |||||||||
| NPI: | 1235676453 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ADVANCED ORTHOPEDICS OF OKLAHOMA PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2488 E 81ST ST STE 290 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184942665 | ||||||||
| FaxNumber: | 9189273193 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 E 81ST ST STE 290 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184942665 | ||||||||
| FaxNumber: | 9189273201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2017 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | BERGSTROM | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9189273213 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 208100000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 2081P2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine | 225100000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 207XX0005X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 363AS0400X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363LF0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200712390G | 05 | OK | MEDICAID | 200712390I | 05 | OK | MEDICAID | 200712390K | 05 | OK | MEDICAID | 200712390B | 05 | OK | MEDICAID | 200712390E | 05 | OK | MEDICAID | 200712390L | 05 | OK | MEDICAID | 200712390A | 05 | OK | MEDICAID | 200712390R | 05 | OK | MEDICAID | 200712390M | 05 | OK | MEDICAID | 200712390N | 05 | OK | MEDICAID | 200712390Q | 05 | OK | MEDICAID | 200712390S | 05 | OK | MEDICAID | 200712390T | 05 | OK | MEDICAID | 200712390J | 05 | OK | MEDICAID | 200712390H | 05 | OK | MEDICAID | 200712390O | 05 | OK | MEDICAID | 200712390P | 05 | OK | MEDICAID |