=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942129663
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STONE BLUFF MEDICAL, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/15/2026
-----------------------------------------------------
Last Update Date | 07/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2028 MAHANEY AVE
-----------------------------------------------------
City | TAHLEQUAH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74464-5783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-992-6050
-----------------------------------------------------
Fax | 833-763-2349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2028 MAHANEY AVE
-----------------------------------------------------
City | TAHLEQUAH
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74464-5783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-992-6050
-----------------------------------------------------
Fax | 833-763-2349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | IAN KELLEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-633-0447
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208VP0000X
-----------------------------------------------------
Taxonomy Name | Pain Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------