Basic Information
Provider Information | |||||||||
NPI: | 1629002886 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ADVANCED PERIOPERATIVE SERVICES PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | KELEY J BOOTH MD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6491 | ||||||||
Address2: |   | ||||||||
City: | NORMAN | ||||||||
State: | OK | ||||||||
PostalCode: | 730706491 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9186649892 | ||||||||
FaxNumber: | 9186642521 | ||||||||
Practice Location | |||||||||
Address1: | 4401 S WESTERN AVE | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731093413 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9186649892 | ||||||||
FaxNumber: | 9186642521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 12/08/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOOTH | ||||||||
AuthorizedOfficialFirstName: | KELEY | ||||||||
AuthorizedOfficialMiddleName: | JOHN | ||||||||
AuthorizedOfficialTitleorPosition: | CEO OWNER | ||||||||
AuthorizedOfficialTelephone: | 4059478585 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 200087470A | 05 | OK |   | MEDICAID |