Provider Demographics
NPI:1750828893
Name:OKLAHOMA STATE UNIVERISTY MEDICAL CENTER
Entity Type:Organization
Organization Name:OKLAHOMA STATE UNIVERISTY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-382-4600
Mailing Address - Street 1:717 S HOUSTON AVE
Mailing Address - Street 2:SUITE 400
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74127-9023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:717 S HOUSTON AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74127-9023
Practice Address - Country:US
Practice Address - Phone:918-382-4600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5986282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200652820Medicaid