Provider Demographics
NPI:1306968839
Name:NORTHEAST ORHTOPAEDICS & SPORTS MEDICINE
Entity type:Organization
Organization Name:NORTHEAST ORHTOPAEDICS & SPORTS MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:J
Authorized Official - Last Name:COLE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-701-2000
Mailing Address - Street 1:6312 E 101ST STREET
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-5726
Mailing Address - Country:US
Mailing Address - Phone:918-701-2000
Mailing Address - Fax:918-893-6202
Practice Address - Street 1:6312 E 101ST STREET
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74137
Practice Address - Country:US
Practice Address - Phone:918-701-2000
Practice Address - Fax:918-893-6202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK900522113Medicaid
OKE69138Medicare UPIN