MEDICARE: JTM PIVOT CORP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208VP0000X	Pain Medicine Physician
2	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1497362305
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JTM PIVOT CORP

Provider Business Mailing Address
First Line	:	1708 NW 39TH ST
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73118-2608
Country	:	US
Telephone Number	:	405-315-8180
Fax Number	:	405-216-5724

Provider Business Practice Location Address
First Line	:	800 W 18TH ST STE 100
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73013-3759
Country	:	US
Telephone Number	:	405-315-8180
Fax Number	:	405-216-5724

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JERRY T MCLAUGHLIN
Credential	:	PA-C
Telephone Number	:	405-315-8180

Provider Enumeration Date	:	09/24/2020
Last Update Date	:	09/27/2020

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Directions to “JTM PIVOT CORP ” Practice Location

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