Healthcare Provider Details

I. General information

NPI: 1184152001
Provider Name (Legal Business Name): OKLAHOMA CHRONIC PAIN SPECIALISTS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2017
Last Update Date: 07/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10124 S SHERIDAN RD STE B
TULSA OK
74133-6742
US

IV. Provider business mailing address

10124 S SHERIDAN RD, STE B
TULSA OK
74133
US

V. Phone/Fax

Practice location:
  • Phone: 774-473-9119
  • Fax:
Mailing address:
  • Phone: 774-473-9119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number31431
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number31431
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number31431
License Number StateOK

VIII. Authorized Official

Name: DR. EMAD S ATTALLAH-WASIF
Title or Position: OWNER AND PRESIDENT
Credential: MD
Phone: 774-473-9119