Provider Demographics
NPI:1215192265
Name:SPINE TRANSFORMATION LLC
Entity Type:Organization
Organization Name:SPINE TRANSFORMATION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DERECK
Authorized Official - Middle Name:AARON
Authorized Official - Last Name:PEERY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-223-7200
Mailing Address - Street 1:915 10TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-4025
Mailing Address - Country:US
Mailing Address - Phone:580-223-7200
Mailing Address - Fax:580-223-7207
Practice Address - Street 1:915 10TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-4025
Practice Address - Country:US
Practice Address - Phone:580-223-7200
Practice Address - Fax:580-223-7207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-18
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4546207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200204540AMedicaid
OKB5216Medicare PIN
OK200204540AMedicaid