Healthcare Provider Details

I. General information

NPI: 1144491853
Provider Name (Legal Business Name): RENAL AND HYPERTENSION INSTITUTE OF NORTHEAST OKLAHOMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 09/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1607 S MUSKOGEE AVE SUITE A
TAHLEQUAH OK
74464-5440
US

IV. Provider business mailing address

PO BOX 1008
TAHLEQUAH OK
74465-1008
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-2121
  • Fax:
Mailing address:
  • Phone: 918-453-2121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: MR. BRIAN WOODLIFF
Title or Position: BOARD OF MANAGERS
Credential:
Phone: 918-453-2263