Basic Information
| Provider Information | |||||||||
| NPI: | 1972546018 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4502 E 41ST ST | ||||||||
| Address2: | OU PHYSICIANS TULSA CLINICAL SERVICES | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 741352553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186603632 | ||||||||
| FaxNumber: | 9186603631 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 SOUTH ST. LOUIS AVE | ||||||||
| Address2: | OU PHYSICIANS TULSA FAMILY MEDICINE | ||||||||
| City: | TULSA | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186194600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | MADDY | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO OU PHYSICIANS | ||||||||
| AuthorizedOfficialTelephone: | 4052713932 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207QS0010X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207V00000X | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 103T00000X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 101YP2500X | X | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.