Provider Demographics
NPI:1578704938
Name:OKLAHOMA STATE UNIVERSITY MEDICAL TRUST
Entity Type:Organization
Organization Name:OKLAHOMA STATE UNIVERSITY MEDICAL TRUST
Other - Org Name:OKLAHOMA STATE UNIVERSITY MEDICAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN AND TRUSTEE
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:HUDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-492-4418
Mailing Address - Street 1:744 W 9TH ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9020
Mailing Address - Country:US
Mailing Address - Phone:918-587-2561
Mailing Address - Fax:918-599-1750
Practice Address - Street 1:744 W 9TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9020
Practice Address - Country:US
Practice Address - Phone:918-587-2561
Practice Address - Fax:918-599-1750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-16
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK370078Medicare Oscar/Certification