Basic Information
| Provider Information | |||||||||
| NPI: | 1265693444 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AHS TULSA REGIONAL MEDICAL CENTER LLC | ||||||||
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| OtherOrganizationName: | OKLAHOMA STATE UNIVERSITY MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 BURTON HILLS BLVD | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156293 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152963000 | ||||||||
| FaxNumber: | 6152966011 | ||||||||
| Practice Location | |||||||||
| Address1: | 744 W 9TH ST | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185872561 | ||||||||
| FaxNumber: | 9185991750 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2008 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
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| AuthorizedOfficialLastName: | PETROVICH | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SVP | ||||||||
| AuthorizedOfficialTelephone: | 6152963000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ARDENT HEALTH SERVICES LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 283X00000X | 2260 | OK | Y | Hospitals | Rehabilitation Hospital |
ID Information
| ID | Type | State | Issuer | Description | APPLIED FOR | 01 | OK | MEDICARE-APPLIED FOR | OTHER |