Provider Demographics
NPI:1235997883
Name:OKLAHOMA STATE UNIVERSITY
Entity Type:Organization
Organization Name:OKLAHOMA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:POLAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-561-8422
Mailing Address - Street 1:5310 E 31ST ST STE 1300
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5012
Mailing Address - Country:US
Mailing Address - Phone:918-561-1155
Mailing Address - Fax:918-561-1218
Practice Address - Street 1:5310 E 31ST ST STE 1300
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-5012
Practice Address - Country:US
Practice Address - Phone:918-561-1155
Practice Address - Fax:918-561-1218
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OKLAHOMA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-08
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care