1124075627 NPI number — CORVALLIS GASTROENTEROLOGY PC

Table of content: ROBERT W. SMITH M.D. (NPI 1508937723)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124075627 NPI number — CORVALLIS GASTROENTEROLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORVALLIS GASTROENTEROLOGY 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:
1124075627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3521 NW SAMARITAN DR
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
CORVALLIS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97330-4744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-768-6119
Provider Business Mailing Address Fax Number:
541-768-6120

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3521 NW SAMARITAN DR
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
CORVALLIS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97330-4744
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-768-6119
Provider Business Practice Location Address Fax Number:
541-768-6120
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VASDEV
Authorized Official First Name:
SURINDER
Authorized Official Middle Name:
MOHAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
541-768-6116

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , 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: 240038 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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