Healthcare Provider Details

I. General information

NPI: 1053403501
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: 09/29/2006
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4444 E. 41ST ST, 3RD FLOOR, STE C OU PHYSICIANS TULSA PSYCHIATRY
TULSA OK
74125-2527
US

IV. Provider business mailing address

OU PHYSICIANS TULSA-CLINICAL SERVICE 4502 E. 41ST STREET, 2G09
TULSA OK
74135-2553
US

V. Phone/Fax

Practice location:
  • Phone: 918-660-3622
  • Fax: 918-660-3611
Mailing address:
  • Phone: 918-660-3632
  • Fax: 918-660-3631

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

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