=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922081959
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2005
-----------------------------------------------------
Last Update Date | 10/15/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6585 S YALE AVE STE 200
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-8384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-481-2767
-----------------------------------------------------
Fax | 918-481-7639
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6585 S YALE AVE STE 200
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74136-8384
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-481-2767
-----------------------------------------------------
Fax | 918-481-7639
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR CEO
-----------------------------------------------------
Name | MR. DAVID R. LONG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-481-7644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | 18573
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------