Provider Demographics
NPI:1376678508
Name:MEDIC-AIRE OF TAHLEQUAH, INC.
Entity Type:Organization
Organization Name:MEDIC-AIRE OF TAHLEQUAH, INC.
Other - Org Name:MEDIC-AIRE OF TULSA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRES/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JON
Authorized Official - Middle Name:T
Authorized Official - Last Name:HISELEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-9991
Mailing Address - Street 1:17900 S MUSKOGEE AVE
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-5494
Mailing Address - Country:US
Mailing Address - Phone:918-453-9991
Mailing Address - Fax:918-207-0967
Practice Address - Street 1:5059 S YALE AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-7010
Practice Address - Country:US
Practice Address - Phone:918-270-1941
Practice Address - Fax:918-270-1961
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MEDIC-AIRE OF TAHLEQUAH, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-21
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK5858280002Medicare NSC