Basic Information
| Provider Information | |||||||||
| NPI: | 1255964128 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OSU CENTER FOR HEALTH SCIENCES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2345 SOUTHWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741072705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185618306 | ||||||||
| FaxNumber: | 9185615747 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 NW 31ST ST FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAWTON | ||||||||
| State: | OK | ||||||||
| PostalCode: | 735056100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185618306 | ||||||||
| FaxNumber: | 9185615747 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2020 | ||||||||
| LastUpdateDate: | 02/19/2020 | ||||||||
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| AuthorizedOfficialLastName: | POLAK | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT FOR ADMIN/FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 9185618422 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.