Basic Information
Provider Information | |||||||||
NPI: | 1477674711 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NEUROSURGICAL SERVICES PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | DEPT. 96-0321 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731960321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058132600 | ||||||||
FaxNumber: | 4058132633 | ||||||||
Practice Location | |||||||||
Address1: | 4600 SE 29TH ST | ||||||||
Address2: | 760 | ||||||||
City: | DEL CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731153406 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058132600 | ||||||||
FaxNumber: | 4058132633 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/03/2007 | ||||||||
LastUpdateDate: | 03/10/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARRY | ||||||||
AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 4058132600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 174400000X | 24324 | OK | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 200057730A | 05 | OK |   | MEDICAID |