Basic Information
Provider Information | |||||||||
NPI: | 1457573941 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TOM SHI CONNALLY MD PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1330 | ||||||||
Address2: |   | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730701330 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053076668 | ||||||||
FaxNumber: | 4053076660 | ||||||||
Practice Location | |||||||||
Address1: | 500 EAST ROBINSON | ||||||||
Address2: | SUITE 2300 | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730716771 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4053294102 | ||||||||
FaxNumber: | 4053643476 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/03/2007 | ||||||||
LastUpdateDate: | 01/15/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONNALLY | ||||||||
AuthorizedOfficialFirstName: | TOM | ||||||||
AuthorizedOfficialMiddleName: | SHI | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4053294102 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 23363 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 200014890B | 05 | OK |   | MEDICAID | P00072417 | 01 | OK | MEDICARE RAILROAD | OTHER | 200014890A | 05 | OK |   | MEDICAID |