Basic Information
Provider Information | |||||||||
NPI: | 1922081959 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6585 S YALE AVE | ||||||||
Address2: | STE 200 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741368384 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184812767 | ||||||||
FaxNumber: | 9184817639 | ||||||||
Practice Location | |||||||||
Address1: | 6585 S YALE AVE | ||||||||
Address2: | STE 200 | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741368384 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184812767 | ||||||||
FaxNumber: | 9184817639 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/23/2005 | ||||||||
LastUpdateDate: | 10/15/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LONG | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | R. | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR CEO | ||||||||
AuthorizedOfficialTelephone: | 9184817644 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | 18573 | OK | N |   | Suppliers | Non-Pharmacy Dispensing Site |   | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207X00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 3724437 | 01 |   | NCPDP PROVIDER IDENTIFICATION NUMBER | OTHER | 100031720A | 05 | OK |   | MEDICAID |