MEDICARE: STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCE COLLEGE OF OSTEOPATH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

General Provider Information

NPI Number	:	1124557426
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCE COLLEGE OF OSTEOPATH

Provider Business Mailing Address
First Line	:	5310 E 31ST ST STE 13
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-5013
Country	:	US
Telephone Number	:	918-561-5701
Fax Number	:	918-561-1173

Provider Business Practice Location Address
First Line	:	5310 E 31ST ST STE LL
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-5013
Country	:	US
Telephone Number	:	918-236-4000
Fax Number	:	918-236-4001

Authorized Official
Title or Position	:	VP FOR ADMINISTRATION & FINANCE
Name	:	ERIC POLAK
Credential	:
Telephone Number	:	918-561-8422

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	05/14/2025

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