Provider Demographics
NPI:1245391200
Name:STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCE COLLEGE OF OSTEOPATH
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA - OSU CENTER FOR HEALTH SCIENCE COLLEGE OF OSTEOPATH
Other - Org Name:OSU HOUSTON PARKE INTERNAL MEDICINE & SPECIALTY CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR CLINIC FINANCIAL SERVICES
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-561-8322
Mailing Address - Street 1:2345 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2705
Mailing Address - Country:US
Mailing Address - Phone:918-561-5701
Mailing Address - Fax:
Practice Address - Street 1:635 W 11TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9014
Practice Address - Country:US
Practice Address - Phone:918-382-3190
Practice Address - Fax:918-382-6789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100757080AMedicaid
OKWCDMBMedicare PIN