Healthcare Provider Details

I. General information

NPI: 1972750941
Provider Name (Legal Business Name): ELECTRODIAGNOSTIC MEDICINE OF TULSA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2008
Last Update Date: 11/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9308 S TOLEDO AVE
TULSA OK
74137-2739
US

IV. Provider business mailing address

9308 S TOLEDO AVE
TULSA OK
74137-2739
US

V. Phone/Fax

Practice location:
  • Phone: 918-728-8020
  • Fax: 918-728-8019
Mailing address:
  • Phone: 918-615-6581
  • Fax: 918-893-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY S HALSELL
Title or Position: PROVIDER/PHYSICIAN
Credential: D.O
Phone: 918-728-8020