Basic Information
| Provider Information | |||||||||
| NPI: | 1750828893 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OKLAHOMA STATE UNIVERISTY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 717 S HOUSTON AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 717 S HOUSTON AVE | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741279023 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9183824600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2017 | ||||||||
| LastUpdateDate: | 01/27/2017 | ||||||||
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| AuthorizedOfficialLastName: | DUNCAN | ||||||||
| AuthorizedOfficialFirstName: | SHAWNA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PROGRAM DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9183824600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | DO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282NC2000X | 5986 | OK | Y | Hospitals | General Acute Care Hospital | Children |
ID Information
| ID | Type | State | Issuer | Description | 200652820 | 05 | OK | MEDICAID |