MEDICARE: OKLAHOMA STATE UNIVERSITY

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	261QM2500X	Medical Specialty Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1548329063
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OKLAHOMA STATE UNIVERSITY

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 11
Second Line	:
City	:	TULSA
State	:	OK
Zip	:	74135-5013
Country	:	US
Telephone Number	:	918-584-5364
Fax Number	:	918-584-5394

Authorized Official
Title or Position	:	VP
Name	:	ERIC JOHN POLAK
Credential	:
Telephone Number	:	918-561-8422

Provider Enumeration Date	:	12/08/2006
Last Update Date	:	10/28/2024

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Directions to “OKLAHOMA STATE UNIVERSITY ” Practice Location

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