Healthcare Provider Details

I. General information

NPI: 1184808974
Provider Name (Legal Business Name): BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2007
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6465 S. YALE, STE 304 OU PHYSICIANS TULSA PEDIATRIC SPECIALIST
TULSA OK
74136
US

IV. Provider business mailing address

4502 E. 41ST ST, 2G08 OU PHYSICIANS TULSA-CLINICAL SERVICES
TULSA OK
74135-2527
US

V. Phone/Fax

Practice location:
  • Phone: 918-619-4323
  • Fax: 918-619-4322
Mailing address:
  • Phone: 918-660-3632
  • Fax: 918-660-3631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number
License Number State

VIII. Authorized Official

Name: BRIAN L MADDY
Title or Position: CEO OU PHYSICIANS
Credential:
Phone: 405-271-3932