Provider Demographics
NPI:1083947378
Name:TAHLEQUAH CITY HOSPITAL
Entity Type:Organization
Organization Name:TAHLEQUAH CITY HOSPITAL
Other - Org Name:TMG
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODLIFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-456-0641
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1008
Mailing Address - Country:US
Mailing Address - Phone:918-456-0641
Mailing Address - Fax:918-453-2341
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3324
Practice Address - Country:US
Practice Address - Phone:918-456-0641
Practice Address - Fax:918-453-2341
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TAHLEQUAH HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-09-17
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2178208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty