1871540252 NPI number — JEFFREY K BERT MD

Table of content: JEFFREY K BERT MD (NPI 1871540252)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871540252 NPI number — JEFFREY K BERT MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERT
Provider First Name:
JEFFREY
Provider Middle Name:
K
Provider Name Prefix Text:
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:
1871540252
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/06/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2699 N 17TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-2134
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-266-3600
Provider Business Mailing Address Fax Number:
541-269-0708

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2699 N 17TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-2134
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-266-3600
Provider Business Practice Location Address Fax Number:
541-269-0708
Provider Enumeration Date:
05/30/2006

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: 207X00000X , with the licence number:  MD09764 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: C105001 . This is a "PACIFIC SOURCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 240218 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200025535 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 050922009 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 97420A010 . This is a "TRICARE" identifier . This identifiers is of the category "OTHER".