=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033560966
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEDICAL CONSULTANT SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/22/2016
-----------------------------------------------------
Last Update Date | 06/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3309 W PRINCETON ST
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74012-9587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-819-9498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3309 W PRINCETON ST
-----------------------------------------------------
City | BROKEN ARROW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74012-9587
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-819-9498
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CLINICAL MEDICINE
-----------------------------------------------------
Name | DR. MANSOOR BHATTI
-----------------------------------------------------
Credential | DDS, PHD, PA-C
-----------------------------------------------------
Telephone | 419-819-9498
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------