1336264399 NPI number — JM JEREMY ANDERSON DO

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336264399 NPI number — JM JEREMY ANDERSON DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JM JEREMY ANDERSON DO
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:
1336264399
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
620 NW 11TH ST
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
HERMISTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97838-6941
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-289-7075
Provider Business Mailing Address Fax Number:
541-289-1189

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
620 NW 11TH ST
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
HERMISTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97838-6941
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-289-7075
Provider Business Practice Location Address Fax Number:
541-289-1189
Provider Enumeration Date:
03/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ANDERSON
Authorized Official First Name:
J.M.
Authorized Official Middle Name:
JEREMY
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
541-289-7075

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , 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: 1881630440 . This is a "NPI IND." identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 240454 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: DO26732 . This is a "MD LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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