Provider Demographics
NPI:1639267065
Name:NORTHEASTERN TRIBAL HEALTH SYSTEM
Entity Type:Organization
Organization Name:NORTHEASTERN TRIBAL HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH PROGRAM DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:DAWES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-542-1655
Mailing Address - Street 1:PO BOX 1498
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:OK
Mailing Address - Zip Code:74355-1498
Mailing Address - Country:US
Mailing Address - Phone:918-542-1655
Mailing Address - Fax:918-540-1685
Practice Address - Street 1:7600 S HIGHWAY 69A
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:OK
Practice Address - Zip Code:74354-1016
Practice Address - Country:US
Practice Address - Phone:918-542-1655
Practice Address - Fax:918-540-1685
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEASTERN TRIBAL HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-11
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21-4318332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700600BMedicaid