Provider Demographics
NPI:1417981564
Name:ADVANCE PAIN MANAGEMENT OF OKLAHOMA PC
Entity Type:Organization
Organization Name:ADVANCE PAIN MANAGEMENT OF OKLAHOMA PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-702-8623
Mailing Address - Street 1:5252 N MERIDIAN AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-2178
Mailing Address - Country:US
Mailing Address - Phone:405-702-8623
Mailing Address - Fax:405-608-8800
Practice Address - Street 1:5252 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-2178
Practice Address - Country:US
Practice Address - Phone:405-702-8623
Practice Address - Fax:405-608-8800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDF3411OtherRR MEDICARE
OK617696700OtherUS DEPT OF LABOR
OK20087800AMedicaid
OK20087800AMedicaid
OK200522108Medicare PIN