Provider Demographics
NPI:1306229422
Name:MORGAN VANDERLICK QUALITY PAIN MANAGEMENT, LLC
Entity Type:Organization
Organization Name:MORGAN VANDERLICK QUALITY PAIN MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MORGAN-VANDERLICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-701-2055
Mailing Address - Street 1:1916 W C ST
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-2367
Mailing Address - Country:US
Mailing Address - Phone:918-701-2055
Mailing Address - Fax:918-701-2056
Practice Address - Street 1:1916 W C ST
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-2367
Practice Address - Country:US
Practice Address - Phone:918-701-2055
Practice Address - Fax:918-701-2056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-07
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25659207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK20603340AMedicaid
OK454386Medicare PIN