Provider Demographics
NPI:1003842394
Name:SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY
Entity Type:Organization
Organization Name:SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY
Other - Org Name:SMH REDWOOD CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-774-1100
Mailing Address - Street 1:213 E REDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:SALLISAW
Mailing Address - State:OK
Mailing Address - Zip Code:74955-2811
Mailing Address - Country:US
Mailing Address - Phone:918-774-1100
Mailing Address - Fax:918-774-1143
Practice Address - Street 1:511 E REDWOOD AVE
Practice Address - Street 2:
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-3020
Practice Address - Country:US
Practice Address - Phone:918-774-1100
Practice Address - Fax:918-774-1143
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-25
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2189261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700190MMedicaid
OK100522063Medicare ID - Type UnspecifiedSMH REDWOOD CLINIC