1528159316 NPI number — LEO EUGENE OBERMILLER JR. MD

Table of content: LEO EUGENE OBERMILLER JR. MD (NPI 1528159316)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528159316 NPI number — LEO EUGENE OBERMILLER JR. MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OBERMILLER
Provider First Name:
LEO
Provider Middle Name:
EUGENE
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
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:
1528159316
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/23/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 W 8TH AVE
Provider Second Line Business Mailing Address:
MOTHER GAMELIN BLDG, 3RD FLOOR, ROOM 207305
Provider Business Mailing Address City Name:
SPOKANE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99204-2307
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-474-6842
Provider Business Mailing Address Fax Number:
509-474-6606

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
105 W 8TH AVE STE 1000
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99204-2327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-474-4500
Provider Business Practice Location Address Fax Number:
509-474-4487
Provider Enumeration Date:
09/27/2006

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: 207RN0300X , with the licence number:  025209 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RN0300X , with the licence number: M5092 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: MD00019462 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 000010000219 . This is a "REGENCE BLUE SHIELD OF ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 805903500 , issued by the state of ( ID ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8111304 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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