1487684353 NPI number — DR. MICHAEL PURUCKHERR MD

Table of content: DR. MICHAEL PURUCKHERR MD (NPI 1487684353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487684353 NPI number — DR. MICHAEL PURUCKHERR MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PURUCKHERR
Provider First Name:
MICHAEL
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:
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:
1487684353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 NE 87TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98664-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 NE 87TH AVE
Provider Second Line Business Practice Location Address:
SUITE 250
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98664-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-882-2778
Provider Business Practice Location Address Fax Number:
360-604-1727
Provider Enumeration Date:
07/04/2006

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: 207RC0200X , with the licence number:  MD00043378 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: MD00043378 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 0101266905 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: MD00043378 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RP1001X , with the licence number: 2021046940 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200104425 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: AB32999 . This is a "MEDICARE GROUP" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 7047629 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1120898 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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