Provider Demographics
NPI:1881960771
Name:TAHLEQUAH MEDICAL GROUP LLC
Entity type:Organization
Organization Name:TAHLEQUAH MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-2120
Mailing Address - Street 1:1400 E DOWNING ST
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-3324
Mailing Address - Country:US
Mailing Address - Phone:
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?:Yes
Parent Organization LBN:TAHLEQUAH HOSPITAL AUTHORITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty