Basic Information
| Provider Information | |||||||||
| NPI: | 1649771874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PMO MEDICAL PLLC | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PAIN MANAGEMENT OF OKLAHOMA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 W QUEENS ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | BROKEN ARROW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740121785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187946008 | ||||||||
| FaxNumber: | 9185163447 | ||||||||
| Practice Location | |||||||||
| Address1: | 401 E BROADWAY CT STE A | ||||||||
| Address2: | |||||||||
| City: | SAND SPRINGS | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740637931 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182463456 | ||||||||
| FaxNumber: | 9185163447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/22/2018 | ||||||||
| LastUpdateDate: | 02/22/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HALFORD | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9187946008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2081P2900X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Pain Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200618300 | 05 | OK | MEDICAID |