Provider Demographics
NPI:1477829554
Name:MEDICAL CENTER PAIN CLINIC, PLLC
Entity Type:Organization
Organization Name:MEDICAL CENTER PAIN CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-232-8003
Mailing Address - Street 1:2700 NE 63RD ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73111-8305
Mailing Address - Country:US
Mailing Address - Phone:405-271-5859
Mailing Address - Fax:405-232-8808
Practice Address - Street 1:1226 N SHARTEL AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103
Practice Address - Country:US
Practice Address - Phone:405-232-8003
Practice Address - Fax:405-232-8808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-22
Last Update Date:2018-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15874261QP3300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200432890AMedicaid
OKOKA105686Medicare PIN