Provider Demographics
NPI:1568680296
Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA - OU MARY MAHONEY
Entity Type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIVERSITY OF OKLAHOMA - OU MARY MAHONEY
Other - Org Name:OU PHYSICIANS MARY MAHONEY
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MADDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-271-1515
Mailing Address - Street 1:1122 NE 13TH ST
Mailing Address - Street 2:ORI 236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12716 NE 36TH STREET
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73140
Practice Address - Country:US
Practice Address - Phone:405-769-3301
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100744720DMedicaid