MEDICARE: BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA - OU MARY MAHONEY

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	261Q00000X	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	:	1568680296
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA - OU MARY MAHONEY

Provider Business Mailing Address
First Line	:	1122 NE 13TH ST
Second Line	:	ORI 236
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73117-1039
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	12716 NE 36TH STREET
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73140
Country	:	US
Telephone Number	:	405-769-3301
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	BRIAN MADDY
Credential	:
Telephone Number	:	405-271-1515

Provider Enumeration Date	:	04/20/2007
Last Update Date	:	09/28/2009

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