NPIMap

Organization Active NPI

Sequoyah County-City of Sallisaw Hospital Authority

  • Family Medicine Physician
  • Sallisaw, OK
National Provider Identifier
1043959141
Registry record updated Apr 20, 2023
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY
Practice address
511 E Redwood Ave
Sallisaw, OK 74955-3020
Phone
(918) 775-1619
Fax
(918) 775-1618
NPI assigned
May 27, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 20, 2023

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

Authorized official

Name
Stephanie Six
Title
Director
Phone
(918) 774-1100

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193400000X SINGLE SPECIALTY GROUP 207Q00000X Primary

Addresses

Primary practice location

511 E Redwood Ave
Sallisaw, OK 74955-3020

Mailing address

213 E Redwood Ave
Sallisaw, OK 74955-2811
Phone (191) 877-4111

Other names 1

  • Northeastern Health System Sequoyah Doing business as

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in OK

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20220823003231 OK Part A Provider - Rural Health Clinic 1759282239 Practice locations: Sallisaw, OK

Rural health clinic certification: CCN 378559

Legal name
SEQUOYAH COUNTY CITY OF SALLISAW HOSPITAL AUTHORITY
Doing business as
SEQUOYAH FAMILY CLINIC
Certification status
Active
Provider type (POS)
Rural health clinic
Participating since
Aug 28, 2023
Last certification
Aug 28, 2023
Ownership / control type
2A
Organization structure
OtherProprietary
Incorporated
Jul 1, 1966 in OK
Enrollment address
511 E Redwood Ave
Sallisaw, OK 74955-3020
Related CCNs
370112

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

Other NPIs with the same Medicare PAC ID 4

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

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
37D2217020Sequoyah Family Clinic511 E Redwood Ave, Sallisaw, OK 74955Certificate of waiverMar 16, 2027

National Provider Directory

National Provider Directory
Tax ID family
Sequoyah County City Trust14 organizations share this tax ID, including this one

Other organizations with this tax ID 13

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

View all 13

Ownership & related parties

All disclosed owners & managing parties 7

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

NameRoleSinceShare
Darren Girnder Individual Corporate OfficerTreasurer Jun 30, 2020
William R Anderson Individual Corporate OfficerTrustee Jun 30, 2021
Debbie Bartel Individual Corporate OfficerTrustee Jun 30, 2022
Cassie Armstrong Individual Corporate Director Sep 1, 2018
Eric Carter Individual Contracted Managing EmployeeDirector of Operations Sep 1, 2018
Todd Martin Individual Corporate OfficerChairman Jun 30, 2020
Bryan Warner Individual Corporate OfficerVice-Chairman Jun 30, 2022

Owners & managing parties with NPI records 1

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

All facility ownership & control disclosures 1

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

FacilityTypeRoleSince
Northeastern Health System SequoyahSallisaw, OK, CCN 370112 Hospital Operational/Managerial Control (100%) Jul 1, 1966

Owned or controlled facilities with NPI records 1

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

NPI Registry JSON

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

{
    "created_epoch": "1653609600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1681948800000",
    "number": "1043959141",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "213 E REDWOOD AVE",
            "city": "SALLISAW",
            "state": "OK",
            "postal_code": "749552811",
            "telephone_number": "191-877-4111"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "511 E REDWOOD AVE",
            "city": "SALLISAW",
            "state": "OK",
            "postal_code": "749553020",
            "telephone_number": "918-775-1619",
            "fax_number": "918-775-1618"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "SEQUOYAH COUNTY-CITY OF SALLISAW HOSPITAL AUTHORITY",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-05-27",
        "last_updated": "2023-04-20",
        "certification_date": "2023-04-20",
        "status": "A",
        "authorized_official_last_name": "SIX",
        "authorized_official_first_name": "STEPHANIE",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "918-774-1100"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Northeastern Health System Sequoyah",
            "code": "3",
            "type": "Doing Business As"
        },
        {
            "organization_name": "Northeastern Health System Sequoyah",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Sallisaw, OK

Sources for this page

Verify at the official NPI Registry.