Basic Information
Provider Information | |||||||||
NPI: | 1134293236 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OSU CENTER FOR HEALTH SCIENCES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | OSU-AJ FAMILY MEDICAL CLINIC OF WESTERN OKLAHOMA | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2345 SOUTHWEST BLVD | ||||||||
Address2: |   | ||||||||
City: | TULSA | ||||||||
State: | OK | ||||||||
PostalCode: | 741072705 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185618306 | ||||||||
FaxNumber: | 9185615747 | ||||||||
Practice Location | |||||||||
Address1: | 411 N RANDALL AVE | ||||||||
Address2: |   | ||||||||
City: | ELK CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 736444127 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9185618306 | ||||||||
FaxNumber: | 9185615747 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 04/07/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | POLAK | ||||||||
AuthorizedOfficialFirstName: | ERIC | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FOR ADMIN/FINANCE | ||||||||
AuthorizedOfficialTelephone: | 9185618422 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
ID | Type | State | Issuer | Description | 200091560C | 05 | OK |   | MEDICAID |