Basic Information
| Provider Information | |||||||||
| NPI: | 1134163942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA | ||||||||
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| OtherOrganizationName: | OU PHYSICIANS TULSA PEDIATRICS | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4502 E 41ST ST 2G08 | ||||||||
| Address2: | OU PHYSICIANS TULSA CLINICAL AFFAIRS | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186603632 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4444 E 41ST STREET 3RD FLOOR STE B | ||||||||
| Address2: | SCHUSTERMAN CENTER CLINIC | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352527 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194300 | ||||||||
| FaxNumber: | 9186194322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 08/09/2007 | ||||||||
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| AuthorizedOfficialLastName: | MADDY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO OU PHYSICIANS | ||||||||
| AuthorizedOfficialTelephone: | 4052713932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0006X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080P0206X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | 2080P0208X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Infectious Diseases | 2080P0216X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Rheumatology | 2080N0001X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 208000000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.