=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942703665
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHEAST OKLAHOMA SPINE AND SPORTS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/09/2018
-----------------------------------------------------
Last Update Date | 03/09/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6048A S SHERIDAN RD
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74145-9212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-518-5013
-----------------------------------------------------
Fax | 918-417-7864
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6048A S SHERIDAN RD
-----------------------------------------------------
City | TULSA
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74145-9212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-518-5013
-----------------------------------------------------
Fax | 918-417-7864
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARK BILLY WILLITS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 918-518-5013
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------