Basic Information
| Provider Information | |||||||||
| NPI: | 1871616490 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STILLWATER ORTHOPAEDIC CLINIC INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STILLWATER ORTHOPEDIC AND SPORTS MEDICINE CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 N PERKINS RD | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740755513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057077500 | ||||||||
| FaxNumber: | 4057079948 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 N PERKINS RD | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740755513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057077500 | ||||||||
| FaxNumber: | 4057079948 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 05/08/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COUCH | ||||||||
| AuthorizedOfficialFirstName: | CARY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 4057077500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.