1811919913 NPI number — KLAMATH ORTHOPEDIC CLINIC PC

Table of content: (NPI 1811919913)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811919913 NPI number — KLAMATH ORTHOPEDIC CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KLAMATH ORTHOPEDIC CLINIC PC
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:
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:
1811919913
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/14/2017
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:
OREGON
Provider Business Mailing Address Postal Code:
97601-1121
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
541-884-7746
Provider Business Mailing Address Fax Number:
541-274-5705

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2200 BRYANT WILLIAMS DR
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:
541-274-5705
Provider Enumeration Date:
07/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GANSBERG
Authorized Official First Name:
JEANNETTE
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
541-274-2902

Provider Taxonomy Codes

  • Taxonomy code: 174400000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 098830 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200010673 . This is a "RAILROAD 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: CO3632 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500679872 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01702513 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 040592 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 261198 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 274622 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01815487 . This is a "RAIL ROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 284783 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500721344 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01432107 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 002635000 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 200044954 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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