Basic Information
| Provider Information | |||||||||
| NPI: | 1245909308 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA STATE UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5310 E 31ST ST FL 13 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741355018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185615701 | ||||||||
| FaxNumber: | 9185611173 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 ATHLETICS CENTER | ||||||||
| Address2: | |||||||||
| City: | STILLWATER | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740780001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057445430 | ||||||||
| FaxNumber: | 4057444945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/10/2021 | ||||||||
| LastUpdateDate: | 09/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | POLAK | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | VP ADMINISTRATIVE AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 9185618422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OKLAHOMA STATE UNIVERSITY | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 207X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207QS0010X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100757080A | 05 | OK | MEDICAID | 684577 | 01 | OK | MEDICARE | OTHER |