Provider Demographics
NPI:1942253521
Name:ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC.
Entity Type:Organization
Organization Name:ABSENTEE SHAWNEE TRIBAL HEALTH AUTHORITY, INC.
Other - Org Name:ABSENTEE SHAWNEE TRIBAL HEALTH SYSTEM - SHAWNEE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:MAL, FACHE, CMPE, CH
Authorized Official - Phone:405-447-0300
Mailing Address - Street 1:15951 LITTLE AXE DRIVE
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73026-9001
Mailing Address - Country:US
Mailing Address - Phone:405-447-0300
Mailing Address - Fax:405-701-7914
Practice Address - Street 1:2029 S GORDON COOPER DRIVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801
Practice Address - Country:US
Practice Address - Phone:405-878-5850
Practice Address - Fax:405-214-4227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100699860KMedicaid
OK100699860JMedicaid
OK100699860JMedicaid
OK700522131Medicare PIN