Provider Demographics
NPI:1396803060
Name:CNS SURGERY INC
Entity type:Organization
Organization Name:CNS SURGERY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:BERRY
Authorized Official - Last Name:FULLENWIDER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-682-8087
Mailing Address - Street 1:333 S 38TH ST STE F
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4937
Mailing Address - Country:US
Mailing Address - Phone:918-682-8087
Mailing Address - Fax:918-682-6449
Practice Address - Street 1:333 S 38TH ST STE F
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4937
Practice Address - Country:US
Practice Address - Phone:918-682-8087
Practice Address - Fax:918-682-6449
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK12300207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKC94945Medicare UPIN