Provider Demographics
NPI:1427279561
Name:OKLAHOMA PHYSICAL MEDICINE AND REHABILITATION, PC
Entity type:Organization
Organization Name:OKLAHOMA PHYSICAL MEDICINE AND REHABILITATION, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETTINGELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:918-252-7952
Mailing Address - Street 1:10026 S MINGO RD STE A
Mailing Address - Street 2:PMB 234
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-5717
Mailing Address - Country:US
Mailing Address - Phone:918-252-7952
Mailing Address - Fax:
Practice Address - Street 1:1621 S EUCALYPTUS AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5940
Practice Address - Country:US
Practice Address - Phone:918-252-7952
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK434452335005OtherBLUE CROSS BLUE SHIELD
OK434452335005OtherBLUE CROSS BLUE SHIELD