Provider Demographics
NPI:1922081959
Name:CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC
Entity Type:Organization
Organization Name:CENTRAL STATES ORTHOPEDIC SPECIALISTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:LONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-481-7644
Mailing Address - Street 1:6585 S YALE AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74136-8384
Mailing Address - Country:US
Mailing Address - Phone:918-481-2767
Mailing Address - Fax:918-481-7639
Practice Address - Street 1:6585 S YALE AVE
Practice Address - Street 2:STE 200
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-8384
Practice Address - Country:US
Practice Address - Phone:918-481-2767
Practice Address - Fax:918-481-7639
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-23
Last Update Date:2011-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207X00000X, 332B00000X
OK18573332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332900000XSuppliersNon-Pharmacy Dispensing Site
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
3724437OtherNCPDP PROVIDER IDENTIFICATION NUMBER
OK100031720AMedicaid
3724437OtherNCPDP PROVIDER IDENTIFICATION NUMBER