Basic Information
| Provider Information | |||||||||
| NPI: | 1982764171 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OSU OWASSO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10512 N. 110TH E. AVE | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74055 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 10512 N. 110TH E. AVE | ||||||||
| Address2: | |||||||||
| City: | OWASSO | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187475322 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2006 | ||||||||
| LastUpdateDate: | 09/16/2008 | ||||||||
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| AuthorizedOfficialLastName: | PENICK | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | ASSOCIATE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9185618322 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.