Provider Demographics
NPI:1649540121
Name:ENID PAIN AND SPINE
Entity type:Organization
Organization Name:ENID PAIN AND SPINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:CHAD
Authorized Official - Last Name:OWENS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:580-234-7246
Mailing Address - Street 1:DEPT 960356
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73196-0001
Mailing Address - Country:US
Mailing Address - Phone:580-234-7246
Mailing Address - Fax:580-233-2223
Practice Address - Street 1:427 E CHEROKEE AVE
Practice Address - Street 2:
Practice Address - City:ENID
Practice Address - State:OK
Practice Address - Zip Code:73701-5823
Practice Address - Country:US
Practice Address - Phone:580-234-7246
Practice Address - Fax:580-233-2223
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-30
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKAPA2056363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty