Basic Information
| Provider Information | |||||||||
| NPI: | 1124152962 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC. | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15951 LITTLE AXE DRIVE | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Practice Location | |||||||||
| Address1: | 15951 LITTLE AXE DR | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730269088 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054470300 | ||||||||
| FaxNumber: | 4057017914 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 4054470300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MAL, FACHE, CMPE, CH | ||||||||
| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | N | Ambulatory Health Care Facilities | Clinic/Center | 261QM1300X | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100699860P | 05 | OK | MEDICAID | 100699860N | 05 | OK | MEDICAID | 100699860A | 05 | OK | MEDICAID | 100699860O | 05 | OK | MEDICAID |