Healthcare Provider Details

I. General information

NPI: 1639267065
Provider Name (Legal Business Name): NORTHEASTERN TRIBAL HEALTH SYSTEM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 12/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7600 S HIGHWAY 69A
MIAMI OK
74354-1016
US

IV. Provider business mailing address

PO BOX 1498
MIAMI OK
74355-1498
US

V. Phone/Fax

Practice location:
  • Phone: 918-542-1655
  • Fax: 918-540-1685
Mailing address:
  • Phone: 918-542-1655
  • Fax: 918-540-1685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License Number21-4318
License Number StateOK

VIII. Authorized Official

Name: SHARON DAWES
Title or Position: HEALTH PROGRAM DIRECTOR
Credential:
Phone: 918-542-1655