Healthcare Provider Details

I. General information

NPI: 1972872448
Provider Name (Legal Business Name): OKLAHOMA MEDICAL PAIN MANAGEMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2011
Last Update Date: 08/14/2023
Certification Date: 08/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 SW 89TH ST STE C
OKLAHOMA CITY OK
73139-9106
US

IV. Provider business mailing address

107006 N 3600 RD
PADEN OK
74860-7101
US

V. Phone/Fax

Practice location:
  • Phone: 405-703-8860
  • Fax: 405-900-4985
Mailing address:
  • Phone: 405-932-1234
  • Fax: 405-932-1248

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number4354
License Number StateOK

VIII. Authorized Official

Name: SCOTT MAYER
Title or Position: CEO
Credential:
Phone: 720-219-5856