Basic Information
| Provider Information | |||||||||
| NPI: | 1780109652 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PMO MEDICAL PLLC | ||||||||
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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: | 3807 W CHEROKEE AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749552452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185147662 | ||||||||
| FaxNumber: | 9187760955 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2017 | ||||||||
| LastUpdateDate: | 08/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | HALFORD | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER / PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9187946008 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PMO MEDICAL PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207LP2900X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207RS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Sports Medicine | 208VP0000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Pain Medicine |
No ID Information.