Basic Information
Provider Information | |||||||||
NPI: | 1003865999 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEASTERN HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | TAHLEQUAH CITY HOSPITAL | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 E DOWNING ST | ||||||||
Address2: | PO BOX 1008 | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744643324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184560641 | ||||||||
FaxNumber: | 9184568886 | ||||||||
Practice Location | |||||||||
Address1: | 1400 E DOWNING ST | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744643324 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184560641 | ||||||||
FaxNumber: | 9184568886 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2006 | ||||||||
LastUpdateDate: | 11/20/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WOODLIFF | ||||||||
AuthorizedOfficialFirstName: | BRIAN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 9184560641 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 2178 | OK | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 332B00000X | 2178 | OK | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 282N00000X | 2178 | OK | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 000370089001 | 01 | OK | BCBS | OTHER | 100700680A | 05 | OK |   | MEDICAID |