1083715262 NPI number — SOUTHEAST UROLOGY CLINIC A PC

Table of content: (NPI 1083715262)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083715262 NPI number — SOUTHEAST UROLOGY CLINIC A PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHEAST UROLOGY CLINIC A 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:
1083715262
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1311 E DIVISION ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-424-7991
Provider Business Mailing Address Fax Number:
360-424-5441

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3100 TONGASS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KETCHIKAN
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99901-5746
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-225-1896
Provider Business Practice Location Address Fax Number:
360-428-4377
Provider Enumeration Date:
09/26/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SAMTMANA
Authorized Official First Name:
EVA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
AMINISTRATOR
Authorized Official Telephone Number:
360-424-7991

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  121467 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: GR0126 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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