Basic Information
| Provider Information | |||||||||
| NPI: | 1316437494 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCE COLLEGE OF OSTEOPATH | ||||||||
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| OtherOrganizationName: | OSU PHYSICIANS SOUTH TULSA OBGYN | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2401 SOUTHWEST BLVD | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741072726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185615701 | ||||||||
| FaxNumber: | 9185611173 | ||||||||
| Practice Location | |||||||||
| Address1: | 8803 S 101ST EAST AVE STE 210 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741335730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182943430 | ||||||||
| FaxNumber: | 9182943910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 05/15/2018 | ||||||||
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| AuthorizedOfficialLastName: | OVERFIELD | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9185615714 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | WCDMB | 01 | OK | MEDICARE | OTHER |