MEDICARE: SOONER PAIN CLINIC, LLC

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	208VP0014X	Interventional Pain Medicine Physician	18162	OK

General Provider Information

NPI Number	:	1164893228
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOONER PAIN CLINIC, LLC

Provider Business Mailing Address
First Line	:	PO BOX 270663
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73137-0663
Country	:	US
Telephone Number	:	405-775-9350
Fax Number	:	405-775-9350

Provider Business Practice Location Address
First Line	:	5509 MAIN ST
Second Line	:	SUITE 100
City	:	DEL CITY
State	:	OK
Zip	:	73115-5510
Country	:	US
Telephone Number	:	405-604-0901
Fax Number	:	405-604-0902

Authorized Official
Title or Position	:	OWNER
Name	:	GEORGE B DAWSON
Credential	:	M.D.
Telephone Number	:	405-604-0901

Provider Enumeration Date	:	10/15/2015
Last Update Date	:	12/09/2015

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