Provider Demographics
NPI:1851764708
Name:OKLAHOMA SPORTS & SPINE MEDICINE,PLLC
Entity Type:Organization
Organization Name:OKLAHOMA SPORTS & SPINE MEDICINE,PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:FRALEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:405-513-3354
Mailing Address - Street 1:PO BOX 54589
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73154-1589
Mailing Address - Country:US
Mailing Address - Phone:405-513-3354
Mailing Address - Fax:
Practice Address - Street 1:121 NE 50TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-1809
Practice Address - Country:US
Practice Address - Phone:405-513-3354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-10-31
Last Update Date:2015-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK26519208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty