Healthcare Provider Details

I. General information

NPI: 1184872004
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: 09/04/2008
Last Update Date: 09/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S. QUINCY AVE. OUPTCH-LAURA DESTER SHELTER
TULSA OK
74120
US

IV. Provider business mailing address

4502 E 41ST STREET, 2G08 OU PHYSICIANS TULSA-CLINICAL SERVICES
TULSA OK
74135-2529
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

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