1417035031 NPI number — APPLEGATE MEDICAL ASSOCIATES

Table of content: (NPI 1417035031)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417035031 NPI number — APPLEGATE MEDICAL ASSOCIATES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APPLEGATE MEDICAL ASSOCIATES
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
APPLEGATE MEDICAL ASSOCIATES - EAST
Provider Other Organization Name Type Code:
5
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:
1417035031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
689 E 19TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-4304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-868-1876
Provider Business Mailing Address Fax Number:
541-868-0932

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
689 E 19TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-4304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-868-1876
Provider Business Practice Location Address Fax Number:
541-868-0932
Provider Enumeration Date:
11/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ALLCOTT
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
V
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-868-1876

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  MD08934 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261Q00000X , with the licence number: MD11435 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X , with the licence number: MD16571 , 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: 222810 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 230482 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 071324 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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