Healthcare Provider Details

I. General information

NPI: 1063681104
Provider Name (Legal Business Name): OKLAHOMA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2008
Last Update Date: 02/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 ATHLETICS CENTER
STILLWATER OK
74078-0001
US

IV. Provider business mailing address

170 ATHLETICS CENTER
STILLWATER OK
74078-0001
US

V. Phone/Fax

Practice location:
  • Phone: 405-744-5430
  • Fax: 405-744-4945
Mailing address:
  • Phone: 405-744-5430
  • Fax: 405-744-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number17462
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3509
License Number StateOK
# 3
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number465
License Number StateOK

VIII. Authorized Official

Name: MRS. GEORGIA MERI CHAPPELL
Title or Position: ATHLETICS INSURANCE COORDINATOR
Credential:
Phone: 405-744-5430