Provider Demographics
NPI:1689338519
Name:NORTHEASTERN HEALTH SYSTEM
Entity Type:Organization
Organization Name:NORTHEASTERN HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ADRIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-456-0641
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1008
Mailing Address - Country:US
Mailing Address - Phone:918-458-2111
Mailing Address - Fax:
Practice Address - Street 1:1323 W KEETOOWAH ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3462
Practice Address - Country:US
Practice Address - Phone:918-506-6901
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-27
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty