Healthcare Provider Details

I. General information

NPI: 1720153315
Provider Name (Legal Business Name): SOUTHERN PLAINS ORTHOPAEDIC AND SPORTS MEDICINE INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 E SHAWNEE CIRCLE
TAHLEQUAH OK
74464
US

IV. Provider business mailing address

1504 E SHAWNEE CIRCLE
TAHLEQUAH OK
74464
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-0023
  • Fax: 918-453-0027
Mailing address:
  • Phone: 918-453-0023
  • Fax: 918-453-0027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number3240
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0516550001
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerCIGNA GOVERNMENT SERVICES
# 2
Identifier200033584
Identifier TypeOTHER
Identifier StateOK
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: DR. PAUL BIZZLE
Title or Position: OWNER
Credential: DO
Phone: 918-453-0023