Provider Demographics
NPI:1740383603
Name:BOARD OF REGENTS OF THE UNIV OF OKLAHOMA-OU PHYS EDMOND CLINIC
Entity Type:Organization
Organization Name:BOARD OF REGENTS OF THE UNIV OF OKLAHOMA-OU PHYS EDMOND CLINIC
Other - Org Name:OU PHYSICIANS EDMOND CLINIC
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:ORI236
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-1039
Mailing Address - Country:US
Mailing Address - Phone:405-271-1515
Mailing Address - Fax:
Practice Address - Street 1:105 N BRYANT
Practice Address - Street 2:SUITE 305
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73034
Practice Address - Country:US
Practice Address - Phone:405-330-8641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-06
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1173440010OtherDME PALMETTO MEDICARE