Provider Demographics
NPI:1669535787
Name:SHETH PAIN CENTER PC
Entity type:Organization
Organization Name:SHETH PAIN CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MELENIE
Authorized Official - Middle Name:
Authorized Official - Last Name:NACHIMSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-775-9350
Mailing Address - Street 1:PO BOX 108835
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73101-8835
Mailing Address - Country:US
Mailing Address - Phone:405-775-9350
Mailing Address - Fax:405-775-9360
Practice Address - Street 1:4200 W MEMORIAL RD
Practice Address - Street 2:305
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9350
Practice Address - Country:US
Practice Address - Phone:405-841-7899
Practice Address - Fax:405-775-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK14599208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200103130AMedicaid
OK612084900OtherDOL
OKDG2424OtherMEDICARE RR
OK=========002OtherBC/BS
OK6230910001Medicare NSC
OKD35271Medicare UPIN
OK600522353Medicare PIN