Basic Information
| Provider Information | |||||||||
| NPI: | 1013005388 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOARD OF REGENTS OF THE UNIV OF OKLAHOMA-OU PHYSICIANS ADOLESCENT MED | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | OU PHYSICIANS ADOLESCENT MEDICINE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13 | ||||||||
| Address2: | ORI236 | ||||||||
| City: | OKC | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052711515 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1200 CHILDREN'S AVENUE | ||||||||
| Address2: | SUITE 7500 | ||||||||
| City: | OKC | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052712006 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 09/06/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MADDY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 4052711515 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 200021910A | 05 | OK | MEDICAID |