Provider Demographics
NPI:1093771909
Name:FOUNDATION SURGERY AFFILIATE OF NORTHWEST OKLAHO
Entity Type:Organization
Organization Name:FOUNDATION SURGERY AFFILIATE OF NORTHWEST OKLAHO
Other - Org Name:FOUNDATION SURGERY CENTER OF OKLAHOMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP AND CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:NEWMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-608-1706
Mailing Address - Street 1:14000 N. PORTLAND AVENUE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-4004
Mailing Address - Country:US
Mailing Address - Phone:405-608-1700
Mailing Address - Fax:405-608-1800
Practice Address - Street 1:14000 N. PORTLAND AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-4004
Practice Address - Country:US
Practice Address - Phone:405-936-8100
Practice Address - Fax:405-748-5962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0077261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK0077OtherLICENSE
OK200077650 AMedicaid
OK37-C0001056Medicare ID - Type Unspecified