Provider Demographics
NPI:1902072960
Name:BOARD FO REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA
Entity Type:Organization
Organization Name:BOARD FO REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO OU PHYSICIANS
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-271-3932
Mailing Address - Street 1:4502 E 41ST ST 2G08
Mailing Address - Street 2:OU PHYSICIANS TULSA-CLINICAL SERVICES
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-2527
Mailing Address - Country:US
Mailing Address - Phone:918-660-3632
Mailing Address - Fax:918-660-3631
Practice Address - Street 1:2325 SOUTH HARVARD STE 400A
Practice Address - Street 2:OUTACH FAMILY & CHILDREN'S SERVICES
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74114
Practice Address - Country:US
Practice Address - Phone:918-660-3622
Practice Address - Fax:918-660-3611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100755890CMedicaid