Basic Information
| Provider Information | |||||||||
| NPI: | 1003842394 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | SMH REDWOOD CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 213 E REDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749552811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187741100 | ||||||||
| FaxNumber: | 9187741143 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 E REDWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | SALLISAW | ||||||||
| State: | OK | ||||||||
| PostalCode: | 749553020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9187741100 | ||||||||
| FaxNumber: | 9187741143 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2006 | ||||||||
| LastUpdateDate: | 08/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SIX | ||||||||
| AuthorizedOfficialFirstName: | STEPHANIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9187741100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | 2189 | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100700190M | 05 | OK | MEDICAID |