Provider Demographics
NPI:1154845501
Name:OSUMC PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:OSUMC PROFESSIONAL SERVICES LLC
Other - Org Name:OSU MEDICAL GROUP SAND SPRINGS PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:OVERFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-561-5714
Mailing Address - Street 1:514 PLAZA CT
Mailing Address - Street 2:
Mailing Address - City:SAND SPRINGS
Mailing Address - State:OK
Mailing Address - Zip Code:74063-7915
Mailing Address - Country:US
Mailing Address - Phone:918-215-5100
Mailing Address - Fax:918-215-5105
Practice Address - Street 1:514 PLAZA CT
Practice Address - Street 2:
Practice Address - City:SAND SPRINGS
Practice Address - State:OK
Practice Address - Zip Code:74063-7915
Practice Address - Country:US
Practice Address - Phone:918-215-5100
Practice Address - Fax:918-215-5105
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OSUMC PROFESSIONAL SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-07-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5451207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200308130AMedicaid
OKOKA101159OtherMEDICARE
OKDR7481OtherRR MEDICARE PTAN