1326495433 NPI number — OKLAHOMA STATE UNIVERSITY

Table of content: (NPI 1326495433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326495433 NPI number — OKLAHOMA STATE UNIVERSITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OKLAHOMA STATE UNIVERSITY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326495433
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/28/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1111 W 17TH ST # 171
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TULSA
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74107-1886
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-561-1440
Provider Business Practice Location Address Fax Number:
918-561-1173
Provider Enumeration Date:
05/18/2016

Additional Information

Authorized Official

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

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 200608290C , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 37D109477 . This is a "C L I A" identifier . This identifiers is of the category "OTHER".




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