Healthcare Provider Details

I. General information

NPI: 1154845501
Provider Name (Legal Business Name): OSUMC PROFESSIONAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

514 PLAZA CT
SAND SPRINGS OK
74063-7915
US

IV. Provider business mailing address

514 PLAZA CT
SAND SPRINGS OK
74063-7915
US

V. Phone/Fax

Practice location:
  • Phone: 918-215-5100
  • Fax: 918-215-5105
Mailing address:
  • Phone: 918-215-5100
  • Fax: 918-215-5105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number5451
License Number StateOK

VIII. Authorized Official

Name: SAMANTHA OVERFIELD
Title or Position: CREDENTIALING ADMINISTRATOR
Credential:
Phone: 918-561-5714