Basic Information
| Provider Information | |||||||||
| NPI: | 1124557426 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCE COLLEGE OF OSTEOPATH | ||||||||
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| OtherOrganizationName: | OSU PHYSICIANS - BEHAVIORAL MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2345 SOUTHWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741072705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185615701 | ||||||||
| FaxNumber: | 9185611173 | ||||||||
| Practice Location | |||||||||
| Address1: | 2488 E 81ST ST STE 3700 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741374290 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182364000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2017 | ||||||||
| LastUpdateDate: | 06/08/2017 | ||||||||
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| AuthorizedOfficialLastName: | POLAK | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP FOR ADMINISTRATION & FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9185618422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCE COLLEGE OF OSTEOPATH | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 2084P0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.