1063597516 NPI number — DR. SLATER TAI MD

Table of content: DR. SLATER TAI MD (NPI 1063597516)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063597516 NPI number — DR. SLATER TAI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TAI
Provider First Name:
SLATER
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NEIMEYER
Provider Other First Name:
SLATER
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063597516
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 82819
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97282
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-233-5405
Provider Business Mailing Address Fax Number:
503-233-2696

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
880 SE 82ND DRIVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GLADSTONE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-659-5515
Provider Business Practice Location Address Fax Number:
503-659-1994
Provider Enumeration Date:
10/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  MD22330 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 132193 . This is a "PERSONAL MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 164936 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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