1386087831 NPI number — APP THREE RIVERS MEDICAL GROUP

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 1386087831 NPI number — APP THREE RIVERS MEDICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
APP THREE RIVERS MEDICAL GROUP
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:
1386087831
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 748157
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90074-8157
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-789-5250
Provider Business Mailing Address Fax Number:
541-789-5538

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 SW RAMSEY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97527-5554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-472-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
STEFAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
541-789-5190

Provider Taxonomy Codes

  • Taxonomy code: 367H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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