Provider Demographics
NPI:1184152001
Name:OKLAHOMA CHRONIC PAIN SPECIALISTS, PLLC
Entity type:Organization
Organization Name:OKLAHOMA CHRONIC PAIN SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMAD
Authorized Official - Middle Name:S
Authorized Official - Last Name:ATTALLAH-WASIF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:774-473-9119
Mailing Address - Street 1:10124 S SHERIDAN RD, STE B
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133
Mailing Address - Country:US
Mailing Address - Phone:774-473-9119
Mailing Address - Fax:
Practice Address - Street 1:10124 S SHERIDAN RD STE B
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74133-6742
Practice Address - Country:US
Practice Address - Phone:774-473-9119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-23
Last Update Date:2017-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK31431208VP0000X, 208VP0014X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200593270AMedicaid