Provider Demographics
NPI:1841334166
Name:OKLAHOMA SPINE DIAGNOSTIC AND PAIN TREATMENT CENTER PLLC
Entity type:Organization
Organization Name:OKLAHOMA SPINE DIAGNOSTIC AND PAIN TREATMENT CENTER PLLC
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 14459
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73113-0459
Mailing Address - Country:US
Mailing Address - Phone:405-775-9350
Mailing Address - Fax:405-775-9360
Practice Address - Street 1:3200 MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-5014
Practice Address - Country:US
Practice Address - Phone:405-878-9490
Practice Address - Fax:405-878-9492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK19113208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKDH1384OtherMEDICARE RR
OK200119720AMedicaid
OK6252130001OtherDME - CIGNA GOVERNMENT SERVICES
OK6252130001OtherDME - CIGNA GOVERNMENT SERVICES
OK6252130001Medicare NSC