Provider Demographics
NPI:1679760912
Name:OKLAHOMA PAIN MANAGEMENT PLLC
Entity type:Organization
Organization Name:OKLAHOMA PAIN MANAGEMENT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JUSTIN
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:PORTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-360-4705
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:
Practice Address - Street 1:3601 NW 138TH ST
Practice Address - Street 2:STE 200
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-2513
Practice Address - Country:US
Practice Address - Phone:405-242-4100
Practice Address - Fax:405-775-9356
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-01
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200123080AMedicaid
OKDG6361OtherMEDICARE RR
OK=========001OtherBC/BS OF OK
OK200123080AMedicaid
OKDG6361OtherMEDICARE RR
OK=========001OtherBC/BS OF OK