1063454395 NPI number — SALEM EMERGENCY PHYSICIANS SERVICE, PC

Table of content: (NPI 1063454395)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063454395 NPI number — SALEM EMERGENCY PHYSICIANS SERVICE, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALEM EMERGENCY PHYSICIANS SERVICE, 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:
1063454395
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 742547
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-2547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-561-5634
Provider Business Mailing Address Fax Number:
503-814-1071

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
890 OAK STREET
Provider Second Line Business Practice Location Address:
SE BUILDING 'A'
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97301-3905
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-561-5634
Provider Business Practice Location Address Fax Number:
503-814-1071
Provider Enumeration Date:
06/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KELLY
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
503-561-5634

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 015388000 . This is a "BLUE CROSS & BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 042080 . This is a "WASHINGTON L&I" identifier . This identifiers is of the category "OTHER".
  • Identifier: 115808 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7028699 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 168143 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: CR0251 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 68701001 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8902424 . This is a "WASHINGTON CRIME VICTIMS" identifier . This identifiers is of the category "OTHER".




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