MEDICARE: GATEWAY MONITORING SPECIALITIES, 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	204R00000X	Electrodiagnostic Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LC0014886887	OTHER	MO	LICENSE

General Provider Information

NPI Number	:	1992154314
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GATEWAY MONITORING SPECIALITIES, LLC

Provider Business Mailing Address
First Line	:	PO BOX 268977
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73126-8977
Country	:	US
Telephone Number	:	918-895-7680
Fax Number	:	214-317-4888

Provider Business Practice Location Address
First Line	:	9521 RIVERSIDE PKWY
Second Line	:	#338
City	:	TULSA
State	:	OK
Zip	:	74137-7418
Country	:	US
Telephone Number	:	918-895-7680
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	TRASE MAHAN
Credential	:
Telephone Number	:	214-675-0905

Provider Enumeration Date	:	06/07/2016
Last Update Date	:	06/07/2016

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