Provider Demographics
NPI:1700209566
Name:PRECISION PAIN MANAGEMENT OF OKLAHOMA
Entity Type:Organization
Organization Name:PRECISION PAIN MANAGEMENT OF OKLAHOMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTRACTING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRISCOE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-893-9445
Mailing Address - Street 1:4110 S 100TH E. AVE.
Mailing Address - Street 2:STE. 74146
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-3311
Mailing Address - Country:US
Mailing Address - Phone:918-857-7246
Mailing Address - Fax:918-359-5828
Practice Address - Street 1:4110 S. 100TH E. AVE.
Practice Address - Street 2:STE 201
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74146-6936
Practice Address - Country:US
Practice Address - Phone:918-857-7246
Practice Address - Fax:918-359-5828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-30
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK208VP0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOK378052OtherMEDICARE GROUP PTAN
OK200556740AMedicaid