Provider Demographics
NPI:1376513002
Name:NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS INC
Entity Type:Organization
Organization Name:NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSENTHAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-772-3390
Mailing Address - Street 1:PO BOX 751
Mailing Address - Street 2:
Mailing Address - City:HULBERT
Mailing Address - State:OK
Mailing Address - Zip Code:74441-0751
Mailing Address - Country:US
Mailing Address - Phone:918-772-3390
Mailing Address - Fax:918-772-3638
Practice Address - Street 1:1310 E BOONE ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3338
Practice Address - Country:US
Practice Address - Phone:918-456-7700
Practice Address - Fax:918-458-9314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-25
Last Update Date:2020-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200057760AMedicaid
F84144Medicare UPIN