Provider Demographics
NPI:1104567791
Name:NORTHEASTERN HEALTH SYSTEM
Entity type:Organization
Organization Name:NORTHEASTERN HEALTH SYSTEM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVP/HOSPITAL ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:THEODORE
Authorized Official - Last Name:BERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:918-453-2263
Mailing Address - Street 1:PO BOX 1008
Mailing Address - Street 2:
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74465-1008
Mailing Address - Country:US
Mailing Address - Phone:918-458-2457
Mailing Address - Fax:918-772-4505
Practice Address - Street 1:1400 E DOWNING ST
Practice Address - Street 2:
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-3324
Practice Address - Country:US
Practice Address - Phone:918-456-0641
Practice Address - Fax:918-772-4505
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEASTERN HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit