Basic Information
| Provider Information | |||||||||
| NPI: | 1659388965 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHEROKEE NATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SAM HIDER HEALTH CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1069 | ||||||||
| Address2: | |||||||||
| City: | TAHLEQUAH | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744651069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5392342694 | ||||||||
| FaxNumber: | 5392342475 | ||||||||
| Practice Location | |||||||||
| Address1: | 859 E. MELTON DRIVE | ||||||||
| Address2: | |||||||||
| City: | JAY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743464205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9182534271 | ||||||||
| FaxNumber: | 9182534938 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 11/08/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JONES | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | ROBERT | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, HEALTH SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9182531700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | 11/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | OK | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
ID Information
| ID | Type | State | Issuer | Description | 100700620A | 05 | OK | MEDICAID | 370171 | 01 | OK | MEDICARE PART A | OTHER |