Basic Information
| Provider Information | |||||||||
| NPI: | 1174684385 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCES COLLEGE OF OSTEOPAT | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OSU COUNTRY CLUB GARDEN PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2345 SOUTHWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741072705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185615701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 446 W LATIMER ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741065106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185948920 | ||||||||
| FaxNumber: | 9185948926 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 06/25/2008 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WILSON | ||||||||
| AuthorizedOfficialFirstName: | REBECCA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF CLINIC FINANCIAL SERVIC | ||||||||
| AuthorizedOfficialTelephone: | 9185618322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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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 | WCDMB | 05 | OK | MEDICAID |