=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558621342
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOOT & ANKLE SURGEONS OF OKLAHOMA PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2012
-----------------------------------------------------
Last Update Date | 10/18/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13100 N WESTERN AVE STE 200
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73114-1431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-418-4500
-----------------------------------------------------
Fax | 405-418-4501
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 268996
-----------------------------------------------------
City | OKLAHOMA CITY
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73126-8996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-418-4500
-----------------------------------------------------
Fax | 405-418-4501
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | CHRISTOPHER J. GREEN
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 405-418-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 290
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------