Basic Information
| Provider Information | |||||||||
| NPI: | 1780321893 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OKLAHOMA STATE UNIVERSITY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5310 E 31ST ST FL 13 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741355018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185615701 | ||||||||
| FaxNumber: | 9185611173 | ||||||||
| Practice Location | |||||||||
| Address1: | 5310 E 31ST ST STE 1102 | ||||||||
| Address2: | |||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741355018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9185611890 | ||||||||
| FaxNumber: | 9185611889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2022 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| AuthorizedOfficialLastName: | POLAK | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | JOHN | ||||||||
| AuthorizedOfficialTitleorPosition: | VP ADMINISTRATIVE AFFAIRS | ||||||||
| AuthorizedOfficialTelephone: | 9185618422 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OKLAHOMA STATE UNIVERSITY | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
No ID Information.