Basic Information
Provider Information
NPI: 1922081959
EntityType: 2
ReplacementNPI:  
OrganizationName: CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC
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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:  
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AuthorizedOfficialLastName: LONG
AuthorizedOfficialFirstName: DAVID
AuthorizedOfficialMiddleName: R.
AuthorizedOfficialTitleorPosition: ADMINISTRATOR CEO
AuthorizedOfficialTelephone: 9184817644
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
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NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
332900000X18573OKN SuppliersNon-Pharmacy Dispensing Site 
332B00000X  N SuppliersDurable Medical Equipment & Medical Supplies 
207X00000X  Y193400000X SINGLE SPECIALTY GROUPAllopathic & Osteopathic PhysiciansOrthopaedic Surgery 

ID Information
IDTypeStateIssuerDescription
372443701 NCPDP PROVIDER IDENTIFICATION NUMBEROTHER
100031720A05OK MEDICAID


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