Provider Demographics
NPI:1609048545
Name:SOUTHEASTERN OKLAHOMA NEUROSCIENCES
Entity type:Organization
Organization Name:SOUTHEASTERN OKLAHOMA NEUROSCIENCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KIMBALL
Authorized Official - Middle Name:N
Authorized Official - Last Name:PRATT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:580-272-0018
Mailing Address - Street 1:PO BOX 1405
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74821
Mailing Address - Country:US
Mailing Address - Phone:580-272-0018
Mailing Address - Fax:580-272-0657
Practice Address - Street 1:520 N MONTE VISTA ST
Practice Address - Street 2:STE C
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4674
Practice Address - Country:US
Practice Address - Phone:580-272-0018
Practice Address - Fax:580-272-0657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-01
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKOKB5045Medicare PIN