Provider Demographics
NPI:1457574170
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:
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: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:918-456-0641
Mailing Address - Fax:918-456-8886
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:2007-04-11
Last Update Date:2014-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2178207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100700680DMedicaid
OKT37008901Medicare ID - Type UnspecifiedPHYSICIAN GROUP