MEDICARE: SOUTH TULSA ASC, 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	261QA1903X	Ambulatory Surgical Clinic/Center

General Provider Information

NPI Number	:	1174084982
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTH TULSA ASC, LLC

Provider Business Mailing Address
First Line	:	20235 N CAVE CREEK RD # 104-472
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85024-4424
Country	:	US
Telephone Number	:	623-764-2780
Fax Number	:

Provider Business Practice Location Address
First Line	:	9840 E 81ST ST STE 200
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74133-4584
Country	:	US
Telephone Number	:	623-764-2780
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PARTNER
Name	:	MR. TERRANCE WADE O'NEAL
Credential	:
Telephone Number	:	623-764-2780

Provider Enumeration Date	:	03/26/2019
Last Update Date	:	03/26/2019

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