NPIMap

Organization Active NPI

Northeastern Health System

Doing business as Fort Gibson Medical Clinic

  • Rural Health Clinic/Center
  • Fort Gibson, OK
National Provider Identifier
1013458652
Registry record updated Apr 6, 2026
On this page

Key facts

NPPES NPI Registry
Primary specialty
Rural Health Clinic/CenterTaxonomy code 261QR1300X
Legal business name
NORTHEASTERN HEALTH SYSTEM
Doing business as
Fort Gibson Medical Clinic
Practice address
104 Lone Oak Cir
Fort Gibson, OK 74434-5001
Phone
(918) 478-2101
Fax
(918) 478-6008
NPI assigned
Mar 15, 2017
Last updated
Apr 6, 2026By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 6, 2026

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Julie Ward
Title
Cfo
Phone
(918) 453-2120

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Rural Health Clinic/Center 261QR1300X Primary

Addresses

Primary practice location

104 Lone Oak Cir
Fort Gibson, OK 74434-5001

Mailing address

PO Box 500
Tahlequah, OK 74465-0500
Phone (918) 478-2101

Other names 1

  • Fort Gibson Medical Clinic Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20050519001008 OK Part A Provider - Hospital 1456255025 3 other NPIs on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Tahlequah, OK
O20170605000888 OK Part A Provider - Rural Health Clinic 1456255025 Practice locations: Fort Gibson, OK

NPI to CCN mapping 2

The Medicare certification numbers (CCNs) connected to NPI 1013458652. Details of each certification follow.

Hospital certification: CCN 370089

Legal name
NORTHEASTERN HEALTH SYSTEM
Doing business as
TAHLEQUAH CITY HOSPITAL
Certification status
Active
Provider type (POS)
Hospital – Short-term
Participating since
Jul 1, 1966
Last certification
Jun 4, 2025
Beds
98
Ownership / control type
Hospital district or authority
Organization structure
OtherNon-profit
Enrollment address
1400 E Downing St
Tahlequah, OK 74464-3324
Other Hospital Practice Location
Hospital subgroups
General

Rural health clinic certification: CCN 378501

Legal name
NORTHEASTERN HEALTH SYSTEM
Doing business as
FORT GIBSON MEDICAL CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Jul 31, 2017
Last certification
Jun 7, 2023
Ownership / control type
2B
Organization structure
CorporationNon-profit
Incorporated
Jun 3, 1974 in OK
Enrollment address
104 Lone Oak Cir
Fort Gibson, OK 74434-5001
Related CCNs
370089

Facilities connected through Provider of Services related, parent or unit certification numbers.

Other NPIs with the same Medicare PAC ID 7

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 3

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

Care Compare: Hospital

Medicare Care Compare
Listed as
Northeastern Health SystemCCN 370089 · All quality measures
Overall star rating
2 of 5
Type
Acute Care Hospitals
Ownership
Government - Hospital District or Authority
Medicare certification status
ActiveFrom the Provider of Services file
Emergency services
Yes

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
37D1096476Ft Gibson Medical Clinic104 Lone Oak Circle, Fort Gibson, OK 74434Provider-performed microscopyJun 30, 2027

National Provider Directory

National Provider Directory
Tax ID family
Tahlequah City Hospital7 organizations share this tax ID, including this one

Other organizations with this tax ID 6

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 5

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
James Berry Individual Corporate OfficerVP Sep 1, 2016
Northeastern Health System Organization, Tahlequah, OK Operational/Managerial Control May 1, 2008
Brian Woodliff Individual Corporate Director May 19, 2005
W-2 Managing Employee May 19, 2005
Christine Jankas Individual Corporate OfficerVP Physician Services May 14, 2019
Kristen Lemasters Individual W-2 Managing Employee Jul 1, 2022

Owners & managing parties with NPI records 7

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Tahlequah City HospitalTahlequah, OK, CCN 370089 Hospital Operational/Managerial Control May 1, 2008
Tahlequah City HospitalTahlequah, OK, CCN 37S089 Hospital Operational/Managerial Control Oct 1, 2002
Tahlequah City HospitalTahlequah, OK, CCN 37T089 Hospital Operational/Managerial Control Jan 1, 1974

Owned or controlled facilities with NPI records 5

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Practitioners & affiliated clinicians

Affiliated clinicians 335

Clinicians who list this facility as an affiliation in Medicare Care Compare.

View all 335

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1489536000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1775433600000",
    "number": "1013458652",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 500",
            "city": "TAHLEQUAH",
            "state": "OK",
            "postal_code": "744650500",
            "telephone_number": "918-478-2101",
            "fax_number": "918-478-6008"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "104 LONE OAK CIR",
            "city": "FORT GIBSON",
            "state": "OK",
            "postal_code": "744345001",
            "telephone_number": "918-478-2101",
            "fax_number": "918-478-6008"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "NORTHEASTERN HEALTH SYSTEM",
        "organizational_subpart": "NO",
        "enumeration_date": "2017-03-15",
        "last_updated": "2026-04-06",
        "certification_date": "2026-04-06",
        "status": "A",
        "authorized_official_last_name": "WARD",
        "authorized_official_first_name": "JULIE",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "918-453-2120"
    },
    "taxonomies": [
        {
            "code": "261QR1300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Rural Health",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Fort Gibson Medical Clinic",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Fort Gibson, OK

Sources for this page

Verify at the official NPI Registry.