Provider Demographics
NPI:1124139126
Name:PAIN INSTITUTE OF TULSA, INC
Entity type:Organization
Organization Name:PAIN INSTITUTE OF TULSA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:F
Authorized Official - Last Name:SORENSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-496-5195
Mailing Address - Street 1:1145 S UTICA AVE
Mailing Address - Street 2:SUITE 364
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4004
Mailing Address - Country:US
Mailing Address - Phone:918-496-5195
Mailing Address - Fax:918-496-5194
Practice Address - Street 1:1145 S UTICA AVE
Practice Address - Street 2:SUITE 364
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4004
Practice Address - Country:US
Practice Address - Phone:918-496-5195
Practice Address - Fax:918-496-5194
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1434174400000X
OK1732174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200088040AMedicaid
200522110Medicare PIN
OK1346273638Medicare ID - Type UnspecifiedKENDRA JOY HURST, PC-A
OK200088040AMedicaid