Provider Demographics
NPI:1730793696
Name:OSUMC PROFESSIONAL SERVICES LLC
Entity type:Organization
Organization Name:OSUMC PROFESSIONAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:KAY
Authorized Official - Last Name:OVERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-561-5714
Mailing Address - Street 1:2401 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2726
Mailing Address - Country:US
Mailing Address - Phone:918-561-5701
Mailing Address - Fax:918-561-1173
Practice Address - Street 1:112 W 5TH STREET
Practice Address - Street 2:
Practice Address - City:OKMULGEE
Practice Address - State:OK
Practice Address - Zip Code:74447-0000
Practice Address - Country:US
Practice Address - Phone:918-752-1080
Practice Address - Fax:918-752-1081
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSUMC PROFESSIONAL SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty