=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043959141
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/27/2022
-----------------------------------------------------
Last Update Date | 04/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 511 E REDWOOD AVE
-----------------------------------------------------
City | SALLISAW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74955-3020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 918-775-1619
-----------------------------------------------------
Fax | 918-775-1618
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 213 E REDWOOD AVE
-----------------------------------------------------
City | SALLISAW
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74955-2811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 191-877-4111
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | STEPHANIE SIX
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 918-774-1100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------