Healthcare Provider Details

I. General information

NPI: 1477813707
Provider Name (Legal Business Name): OKLAHOMA STATE UNIVERSITY MEDICAL CENTER TRUST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2012
Last Update Date: 05/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

744 W 9TH ST
TULSA OK
74127-9020
US

IV. Provider business mailing address

744 W 9TH ST
TULSA OK
74127-9020
US

V. Phone/Fax

Practice location:
  • Phone: 918-587-2561
  • Fax: 918-599-1750
Mailing address:
  • Phone: 918-587-2561
  • Fax: 918-599-1750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number2260
License Number StateOK

VIII. Authorized Official

Name: MR. JERRY L. HUDSON
Title or Position: TRUSTEE CHAIRMAN
Credential:
Phone: 918-492-4418