1255393419 NPI number — ASHLAND EMERGENCY ASSOCIATES, P.C.

Table of content: (NPI 1255393419)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255393419 NPI number — ASHLAND EMERGENCY ASSOCIATES, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ASHLAND EMERGENCY ASSOCIATES, P.C.
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:
1255393419
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1995 TOLMAN CREEK ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97520-3697
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-488-0679
Provider Business Mailing Address Fax Number:
541-552-9690

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
280 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ASHLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97520-1552
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-482-2441
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
ENNS
Authorized Official First Name:
GORDON
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT/AUTHORIZED GROUP REPRESEN
Authorized Official Telephone Number:
541-488-0679

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: 7094626 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: XGG007121 . This is a "MEDI CAL" identifier . This identifiers is of the category "OTHER".
  • Identifier: 38D0969470 . This is a "CLIA WAIVER" identifier . This identifiers is of the category "OTHER".
  • Identifier: CF8926 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 059936 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 139457 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 023507000 . This is a "BC/BS OF OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 126727 . This is a "WASHINGTON LABOR AND INDU" identifier . This identifiers is of the category "OTHER".
  • Identifier: 453217001 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".




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