Basic Information
| Provider Information | |||||||||
| NPI: | 1609826148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6585 S YALE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741368384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184812767 | ||||||||
| FaxNumber: | 9184817611 | ||||||||
| Practice Location | |||||||||
| Address1: | 6585 S YALE AVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741368384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9184812767 | ||||||||
| FaxNumber: | 9184817611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 11/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | FOX | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF REVENUE CYCLE | ||||||||
| AuthorizedOfficialTelephone: | 9184817616 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 100744260A | 05 | OK | MEDICAID |