Provider Demographics
NPI:1245909308
Name:OKLAHOMA STATE UNIVERSITY
Entity type:Organization
Organization Name:OKLAHOMA STATE UNIVERSITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP ADMINISTRATIVE AFFAIRS
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 1:5310 E 31ST ST FL 13
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-5018
Mailing Address - Country:US
Mailing Address - Phone:918-561-5701
Mailing Address - Fax:918-561-1173
Practice Address - Street 1:170 ATHLETICS CENTER
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:OK
Practice Address - Zip Code:74078-0001
Practice Address - Country:US
Practice Address - Phone:405-744-5430
Practice Address - Fax:405-744-4945
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:OKLAHOMA STATE UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-09-10
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100757080AMedicaid
OK684577OtherMEDICARE