Healthcare Provider Details

I. General information

NPI: 1922081959
Provider Name (Legal Business Name): CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6585 S YALE AVE STE 200
TULSA OK
74136-8384
US

IV. Provider business mailing address

6585 S YALE AVE STE 200
TULSA OK
74136-8384
US

V. Phone/Fax

Practice location:
  • Phone: 918-481-2767
  • Fax: 918-481-7639
Mailing address:
  • Phone: 918-481-2767
  • Fax: 918-481-7639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number18573
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID R. LONG
Title or Position: ADMINISTRATOR CEO
Credential:
Phone: 918-481-7644