Provider Demographics
NPI:1437480670
Name:OKLAHOMA STATE UNIVERSITY
Entity type:Organization
Organization Name:OKLAHOMA STATE UNIVERSITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:VP
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 1:2345 SOUTHWEST BLVD
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74107-2705
Mailing Address - Country:US
Mailing Address - Phone:918-561-5701
Mailing Address - Fax:918-585-9273
Practice Address - Street 1:14002 E 21ST ST STE 1130
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74134-1412
Practice Address - Country:US
Practice Address - Phone:918-439-1200
Practice Address - Fax:918-439-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-28
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical SpecialtyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1306882261OtherOSU GROUP NPI
1306882261OtherOSU GROUP NPI