Basic Information
| Provider Information | |||||||||
| NPI: | 1518004829 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OU PHYSICIANS TULSA CSOS BIXBY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | OU PHYSICIANS TULSA-CLINICAL SERVICES | ||||||||
| Address2: | 4502 E. 41ST STREET, 2G08 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186603632 | ||||||||
| FaxNumber: | 9186603631 | ||||||||
| Practice Location | |||||||||
| Address1: | 12800 S MEMORIAL DR STE D | ||||||||
| Address2: | |||||||||
| City: | BIXBY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 740082577 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183942767 | ||||||||
| FaxNumber: | 9184817611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2007 | ||||||||
| LastUpdateDate: | 07/09/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MADDY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO OU PHYSICIANS | ||||||||
| AuthorizedOfficialTelephone: | 4052713932 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.