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General NPI Number Information
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NPI Number | 1033302906
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Entity Type | Organization
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Legal Business Name | SPINE CARE OF OKLAHOMA, LLC
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Dates
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Enumeration Date | 08/23/2007
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Last Update Date | 08/15/2022
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Provider Practice Location Address
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Address Line | 508 W 15TH ST
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City | EDMOND
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State | OK
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Zip | 73013-3615
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Country | US
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Telephone | 405-840-5100
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Fax | 405-840-5102
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Provider Business Mailing Address
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Address Line | 508 W 15TH ST
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City | EDMOND
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State | OK
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Zip | 73013-3615
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Country | US
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Telephone | 405-615-0290
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Fax | 405-840-5102
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Authorized Official
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Title or Position | BUSINESS OWNER
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Name | DR. EDWARD A SHADID
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Credential | M.D.
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Telephone | 405-840-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 22294
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License Number State | OK
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