Provider Demographics
NPI:1619031465
Name:NORTHEASTERN HEALTH SYSTEM
Entity Type:Organization
Organization Name:NORTHEASTERN HEALTH SYSTEM
Other - Org Name:TAHLEQUAH HOSPITAL AUTHORITY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
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 1:1400 E DOWNING ST
Mailing Address - Street 2:PO BOX 1008
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3324
Mailing Address - Country:US
Mailing Address - Phone:918-456-0641
Mailing Address - Fax:
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-19
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2178273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700680AMedicaid
OK100700680AMedicaid