Basic Information
| Provider Information | |||||||||
| NPI: | 1326234584 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORMAN SURGICAL ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 E ROBINSON ST | ||||||||
| Address2: | 2300 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053294102 | ||||||||
| FaxNumber: | 4053643476 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E ROBINSON ST | ||||||||
| Address2: | 2300 | ||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730716697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4053294102 | ||||||||
| FaxNumber: | 4053643476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2007 | ||||||||
| LastUpdateDate: | 01/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | CONNALLY | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | SHI | ||||||||
| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 4053294102 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 17833 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 24274 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 26881 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | 9306 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 363L00000X | R0054197 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 208600000X | 23363 | OK | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200127940A | 05 | OK | MEDICAID |