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NPI Code Detail

MEDICARE: TAHLEQUAH MEDICAL GROUP LLC

MEDICARE: TAHLEQUAH MEDICAL GROUP LLC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207V00000XObstetrics & Gynecology Physician
2208600000XSurgery Physician
3208800000XUrology Physician
4207R00000XInternal Medicine Physician
5207Q00000XFamily Medicine Physician

General Provider Information

NPI Number : 1881960771
Entity Type Code : Organization
Provider Name (Legal Business Name) : TAHLEQUAH MEDICAL GROUP LLC
Provider Business Mailing Address
First Line : 1400 E DOWNING ST
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-3324
Country : US
Telephone Number : 918-456-0641
Fax Number : 918-453-2341
Provider Business Practice Location Address
First Line : 1400 E DOWNING ST
Second Line :
City : TAHLEQUAH
State : OK
Zip : 74464-3324
Country : US
Telephone Number : 918-456-0641
Fax Number : 918-453-2341
Authorized Official
Title or Position : CEO
Name : JAMES BERRY
Credential :
Telephone Number : 918-456-0641
Provider Enumeration Date : 03/26/2012
Last Update Date : 06/01/2026

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