Provider Demographics
NPI:1306387949
Name:NORTHEASTERN HEALTH SYSTEM
Entity Type:Organization
Organization Name:NORTHEASTERN HEALTH SYSTEM
Other - Org Name:TAHLEQUAH MEDICAL GROUP PRIMARY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-2120
Mailing Address - Street 1:PO BOX 500
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-0500
Mailing Address - Country:US
Mailing Address - Phone:918-207-0991
Mailing Address - Fax:918-456-7570
Practice Address - Street 1:1201 E ROSS BYP
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4188
Practice Address - Country:US
Practice Address - Phone:918-207-0991
Practice Address - Fax:918-456-7570
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-15
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health