Provider Demographics
NPI:1316437494
Name:OKLAHOMA STATE UNIVERSITY
Entity type:Organization
Organization Name:OKLAHOMA STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:POLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-561-8422
Mailing Address - Street 1:5310 E 31ST ST STE 13
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5013
Mailing Address - Country:US
Mailing Address - Phone:918-561-5701
Mailing Address - Fax:918-561-1173
Practice Address - Street 1:6126 E 61ST ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-2117
Practice Address - Country:US
Practice Address - Phone:918-294-3430
Practice Address - Fax:918-294-3910
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKWCDMBOtherMEDICARE