MEDICARE: OZARK NEURO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	204R00000X	Electrodiagnostic Medicine Physician

General Provider Information

NPI Number	:	1093251407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OZARK NEURO

Provider Business Mailing Address
First Line	:	PO BOX 1996
Second Line	:	338
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73101-1996
Country	:	US
Telephone Number	:	214-269-3875
Fax Number	:	903-328-6568

Provider Business Practice Location Address
First Line	:	9521 RIVERSIDE PKWY
Second Line	:	338
City	:	TULSA
State	:	OK
Zip	:	74137-7418
Country	:	US
Telephone Number	:	214-269-3875
Fax Number	:	903-328-6568

Authorized Official
Title or Position	:	BILLING MANAGER
Name	:	GINA SULLIVAN
Credential	:
Telephone Number	:	214-269-3875

Provider Enumeration Date	:	01/09/2017
Last Update Date	:	01/09/2017

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Directions to “OZARK NEURO ” Practice Location

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