Provider Demographics
NPI:1710188818
Name:ULTIMATE SPORTS & ORTHOPEDICS
Entity Type:Organization
Organization Name:ULTIMATE SPORTS & ORTHOPEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:GILLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-338-4400
Mailing Address - Street 1:1754 N ROOSEVELT ST
Mailing Address - Street 2:SUITE # 300
Mailing Address - City:GUYMON
Mailing Address - State:OK
Mailing Address - Zip Code:73942-2730
Mailing Address - Country:US
Mailing Address - Phone:580-338-4400
Mailing Address - Fax:580-338-4402
Practice Address - Street 1:1754 N. ROOSEVELT ST.
Practice Address - Street 2:SUITE # 300
Practice Address - City:GUYMON
Practice Address - State:OK
Practice Address - Zip Code:73942-2730
Practice Address - Country:US
Practice Address - Phone:580-338-4400
Practice Address - Fax:580-338-4402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2008-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK25543207XP3100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XP3100XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryPediatric Orthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5915020001Medicare NSC
OK900522593Medicare PIN