Provider Demographics
NPI:1538226246
Name:TAHLEQUAH INTERNAL MEDICINE INC
Entity type:Organization
Organization Name:TAHLEQUAH INTERNAL MEDICINE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HERBERT
Authorized Official - Middle Name:ROSCOE
Authorized Official - Last Name:LITTLETON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:918-456-0001
Mailing Address - Street 1:1500 E DOWNING
Mailing Address - Street 2:STE 103
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464
Mailing Address - Country:US
Mailing Address - Phone:918-456-0001
Mailing Address - Fax:918-456-6383
Practice Address - Street 1:1500 E DOWNING
Practice Address - Street 2:STE 103
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464
Practice Address - Country:US
Practice Address - Phone:918-456-0001
Practice Address - Fax:918-456-6383
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========001OtherBCBS