Provider Demographics
NPI:1194844936
Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA
Entity Type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA OU PHYSICIANS TULSA
Other - Org Name:OU PHYSICIANS TULSA WAYMAN TISDALE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO OU PHYSICIANS TULSA
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-660-3081
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:74135-2536
Mailing Address - Country:US
Mailing Address - Phone:918-660-3632
Mailing Address - Fax:918-660-3631
Practice Address - Street 1:591 E 36TH ST N
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74106-1812
Practice Address - Country:US
Practice Address - Phone:918-619-8700
Practice Address - Fax:918-634-7884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100745000UMedicaid
OK800522321Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER