1093737199 NPI number — EDWARD L VAN TASSEL DO

Table of content: EDWARD L VAN TASSEL DO (NPI 1093737199)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093737199 NPI number — EDWARD L VAN TASSEL DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN TASSEL
Provider First Name:
EDWARD
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1093737199
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 BRYANT WILLIAMS DRIVE
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
KLAMATH FALLS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97601-1120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-884-7746
Provider Business Mailing Address Fax Number:
541-884-0848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 BRYANT WILLIAMS DRIVE
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
KLAMATH FALLS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97601-1120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-884-7746
Provider Business Practice Location Address Fax Number:
541-884-0848
Provider Enumeration Date:
07/25/2006

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: 207X00000X , with the licence number:  DO25890 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207XX0005X , with the licence number: DO25890 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: P00464722 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 213618 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: XPY145960 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P00419803 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 20889454297601 . This is a "TRICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 820591000 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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