Healthcare Provider Details

I. General information

NPI: 1881099414
Provider Name (Legal Business Name): RMO - TULSA, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2014
Last Update Date: 10/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5522 S LEWIS AVE
TULSA OK
74105-7105
US

IV. Provider business mailing address

635 W 79TH ST
TULSA OK
74132-2645
US

V. Phone/Fax

Practice location:
  • Phone: 918-488-8285
  • Fax:
Mailing address:
  • Phone: 918-488-8285
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARK STEPHEN WILSON
Title or Position: CEO, MEDICAL DIRECTOR
Credential: M.D.
Phone: 918-488-8285