Provider Demographics
NPI:1720354202
Name:MICHELE L NEIL DO, PLLC
Entity Type:Organization
Organization Name:MICHELE L NEIL DO, PLLC
Other - Org Name:FUNCTIONAL MEDICAL INSTITUTE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:L
Authorized Official - Last Name:NEIL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-748-3640
Mailing Address - Street 1:6048 S SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74145-9212
Mailing Address - Country:US
Mailing Address - Phone:918-748-3640
Mailing Address - Fax:918-748-3644
Practice Address - Street 1:6048 S SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9212
Practice Address - Country:US
Practice Address - Phone:918-748-3640
Practice Address - Fax:918-748-3644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4105207R00000X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1902983661Medicare PIN