Basic Information
| Provider Information | |||||||||
| NPI: | 1043653769 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OU PHYSICIANS S OKC FAMILY PRACTICE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1122 NE 13TH ST | ||||||||
| Address2: | ORI 274 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731171039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052711515 | ||||||||
| FaxNumber: | 4052711001 | ||||||||
| Practice Location | |||||||||
| Address1: | 220 SW 89TH ST | ||||||||
| Address2: | SUITE A | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731398504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4056167070 | ||||||||
| FaxNumber: | 4056328495 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2013 | ||||||||
| LastUpdateDate: | 04/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | MADDY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4052713932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA-OU PHYSICIANS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.