Basic Information
Provider Information | |||||||||
NPI: | 1366983850 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEASTERN HEALTH SYSTEM | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | URGENT CARE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 500 | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744650500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184531234 | ||||||||
FaxNumber: | 9184532703 | ||||||||
Practice Location | |||||||||
Address1: | 1203 E ROSS BYP STE A | ||||||||
Address2: |   | ||||||||
City: | TAHLEQUAH | ||||||||
State: | OK | ||||||||
PostalCode: | 744644158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9184531234 | ||||||||
FaxNumber: | 9184532703 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/16/2017 | ||||||||
LastUpdateDate: | 05/18/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WARD | ||||||||
AuthorizedOfficialFirstName: | JULIE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 9184532120 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.