1508921016 NPI number — BRUCE D. CARLSON M.D.

Table of content: (NPI 1508921016)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508921016 NPI number — BRUCE D. CARLSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE D. CARLSON M.D.
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:
HERMISTON FAMILY MEDICINE AND URGENT CARE
Provider Other Organization Name Type Code:
4
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:
1508921016
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
236 E NEWPORT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMISTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97838-2449
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-567-1137
Provider Business Mailing Address Fax Number:
541-567-2336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
236 E NEWPORT AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838-2449
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-567-1137
Provider Business Practice Location Address Fax Number:
541-567-2336
Provider Enumeration Date:
12/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FOSTER
Authorized Official First Name:
TAMI
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
541-567-1137

Provider Taxonomy Codes

  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 223149 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: OR1807 . This is a "HEALTH NET OF OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 080385000 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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