MEDICARE: NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS, INC

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
1	261QF0400X	Federally Qualified Health Center (FQHC)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1891097077
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHEASTERN OKLAHOMA COMMUNITY HEALTH CENTERS, INC

Provider Business Mailing Address
First Line	:	PO BOX 751
Second Line	:
City	:	HULBERT
State	:	OK
Zip	:	74441-0751
Country	:	US
Telephone Number	:	918-772-3390
Fax Number	:	918-772-2244

Provider Business Practice Location Address
First Line	:	1500 E DOWNING ST STE 102
Second Line	:
City	:	TAHLEQUAH
State	:	OK
Zip	:	74464-3354
Country	:	US
Telephone Number	:	918-207-0773
Fax Number	:	918-207-0774

Authorized Official
Title or Position	:	CEO
Name	:	SCOTT ROSENTHAL
Credential	:
Telephone Number	:	918-772-3390

Provider Enumeration Date	:	11/22/2010
Last Update Date	:	06/09/2020

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