1366640070 NPI number — RAYMOND E. ANDREASSEN

Table of content: (NPI 1366640070)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366640070 NPI number — RAYMOND E. ANDREASSEN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RAYMOND E. ANDREASSEN
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:
6
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:
1366640070
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HC 60 BOX 4860
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DELTA JUNCTION
Provider Business Mailing Address State Name:
AK
Provider Business Mailing Address Postal Code:
99737-9440
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
907-895-5100
Provider Business Mailing Address Fax Number:
907-895-5133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2360 SERVICE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DELTA JUNCTION
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99737-9440
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-895-5100
Provider Business Practice Location Address Fax Number:
907-895-5133
Provider Enumeration Date:
07/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CRAWFORD
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
F.
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
907-895-5100

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  AA 2011 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: MD 9969 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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