Healthcare Provider Details

I. General information

NPI: 1831250802
Provider Name (Legal Business Name): OKLAHOMA STATE UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 W 11TH ST
TULSA OK
74127-9014
US

IV. Provider business mailing address

5310 E 31ST ST STE 13
TULSA OK
74135-5013
US

V. Phone/Fax

Practice location:
  • Phone: 918-382-3190
  • Fax: 918-382-6789
Mailing address:
  • Phone: 918-567-5701
  • Fax: 918-561-1173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ERIC JOHN POLAK
Title or Position: VP
Credential:
Phone: 918-561-8422