1558397034 NPI number — ALLA COMARDELLE M.D.

Table of content: ALLA COMARDELLE M.D. (NPI 1558397034)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558397034 NPI number — ALLA COMARDELLE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COMARDELLE
Provider First Name:
ALLA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAKUTONINA
Provider Other First Name:
ALLA
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1558397034
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/13/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5715 BROADWAY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST LINN
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97068-3223
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
504-481-0116
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
KAISER SUNNYSIDE MEDICAL CENTER
Provider Second Line Business Practice Location Address:
10180 SE SUNNYSIDE RD.
Provider Business Practice Location Address City Name:
CLACKAMAS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97015
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-652-2880
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/24/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  026067 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1050890 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".