Provider Demographics
NPI:1588229033
Name:STATE OF OKLAHOMA OSU CENTER FOR HEALTH SCIENCES
Entity Type:Organization
Organization Name:STATE OF OKLAHOMA OSU CENTER FOR HEALTH SCIENCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/CFO
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 1:2401 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2726
Mailing Address - Country:US
Mailing Address - Phone:918-561-1700
Mailing Address - Fax:918-561-1701
Practice Address - Street 1:6333 E SKELLY DR
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-6106
Practice Address - Country:US
Practice Address - Phone:918-561-1700
Practice Address - Fax:918-561-1701
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OKLAHOMA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-05-09
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100757080AMedicaid