1417217894 NPI number — ROSE CITY MEDICAL LLC

Table of content: (NPI 1417217894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417217894 NPI number — ROSE CITY MEDICAL LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSE CITY MEDICAL 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:
ROSE CITY URGENT CARE AND FAMILY PRACTICE
Provider Other Organization Name Type Code:
3
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:
1417217894
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 NE 102ND AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97220-4167
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-894-9005
Provider Business Mailing Address Fax Number:
503-719-4178

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
135 NE 102ND AVE
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:
97220-4167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-894-9005
Provider Business Practice Location Address Fax Number:
503-719-4178
Provider Enumeration Date:
05/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
MARIA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
BUSINESS DIRECTOR
Authorized Official Telephone Number:
503-894-9005

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  85696897 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: 85696897 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 500646730 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: R167408 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com