1205893609 NPI number — CHAR GLENN MD LLC

Table of content: (NPI 1205893609)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205893609 NPI number — CHAR GLENN MD LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHAR GLENN MD LLC
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:
1205893609
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 821350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98682-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-687-5221
Provider Business Mailing Address Fax Number:
360-666-0466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2525 NW LOVEJOY ST STE 405
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-2865
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-274-9818
Provider Business Practice Location Address Fax Number:
503-248-0049
Provider Enumeration Date:
04/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PHILLIPS
Authorized Official First Name:
CHRISTOPHER
Authorized Official Middle Name:
Authorized Official Title or Position:
BILLING MANAGER
Authorized Official Telephone Number:
360-667-3047

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0599990000 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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