Basic Information
| Provider Information | |||||||||
| NPI: | 1477829554 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MEDICAL CENTER PAIN CLINIC, PLLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2700 NE 63RD ST | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731118305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052715859 | ||||||||
| FaxNumber: | 4052328808 | ||||||||
| Practice Location | |||||||||
| Address1: | 1226 N SHARTEL AVE | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052328003 | ||||||||
| FaxNumber: | 4052328808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/22/2012 | ||||||||
| LastUpdateDate: | 07/14/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ELLIS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED AGENT | ||||||||
| AuthorizedOfficialTelephone: | 4052328003 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP3300X | 15874 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Pain |
ID Information
| ID | Type | State | Issuer | Description | 200432890A | 05 | OK | MEDICAID |