Basic Information
| Provider Information | |||||||||
| NPI: | 1568946846 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDICAL CENTER PAIN CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1226 N SHARTEL AVE SUITE 300 | ||||||||
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| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052328003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1226 N SHARTEL AVE SUITE 300 | ||||||||
| Address2: | |||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052328003 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2018 | ||||||||
| LastUpdateDate: | 09/21/2018 | ||||||||
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| AuthorizedOfficialLastName: | MOON | ||||||||
| AuthorizedOfficialFirstName: | BETTY | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 4056058280 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208VP0014X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.