Basic Information
| Provider Information | |||||||||
| NPI: | 1730793696 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSUMC PROFESSIONAL SERVICES LLC | ||||||||
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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: | 112 W 5TH STREET | ||||||||
| Address2: | |||||||||
| City: | OKMULGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744470000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187521080 | ||||||||
| FaxNumber: | 9187521081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/08/2020 | ||||||||
| LastUpdateDate: | 09/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | OVERFIELD | ||||||||
| AuthorizedOfficialFirstName: | SAMANTHA | ||||||||
| AuthorizedOfficialMiddleName: | KAY | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9185615714 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OSUMC PROFESSIONAL SERVICES LLC | ||||||||
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| NPICertificationDate: | 09/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.