1134285091 NPI number — EVAN ROGERS RANSOM MD

Table of content: EVAN ROGERS RANSOM MD (NPI 1134285091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134285091 NPI number — EVAN ROGERS RANSOM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RANSOM
Provider First Name:
EVAN
Provider Middle Name:
ROGERS
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:
1134285091
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1000 S ELISEO DR
Provider Second Line Business Mailing Address:
SUITE 103
Provider Business Mailing Address City Name:
GREENBRAE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94904-2133
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-469-0927
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 S ELISEO DR
Provider Second Line Business Practice Location Address:
SUITE 103
Provider Business Practice Location Address City Name:
GREENBRAE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94904-2133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-469-0927
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2006

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: 207YX0905X , with the licence number:  A117324 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207YX0905X , with the licence number: 259357 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: MD437508 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: FW557A . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: A300045054 . This is a "MEDICARE PTAN" identifier . This identifiers is of the category "OTHER".