Provider Demographics
NPI:1104219385
Name:AVENSTAR PAIN SPECIALISTS, PLLC
Entity Type:Organization
Organization Name:AVENSTAR PAIN SPECIALISTS, PLLC
Other - Org Name:RANDALL PAIN MANAGMENT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-438-0913
Mailing Address - Street 1:1732 S SOONER RD
Mailing Address - Street 2:
Mailing Address - City:MIDWEST CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73110
Mailing Address - Country:US
Mailing Address - Phone:405-438-0913
Mailing Address - Fax:405-438-0958
Practice Address - Street 1:1732 S SOONER RD
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110
Practice Address - Country:US
Practice Address - Phone:405-438-0913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-11
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4691207QS0010X
OK2493208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200341890AMedicaid
OK1902078298Medicare UPIN
OKAAA1578Medicare PIN