1669785820 NPI number — SEAN MCELLIGOTT

Table of content: SEAN MCELLIGOTT (NPI 1669785820)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669785820 NPI number — SEAN MCELLIGOTT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCELLIGOTT
Provider First Name:
SEAN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1669785820
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 MEADOW RD APT 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RUTHERFORD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07070-2009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1200 HILYARD ST
Provider Second Line Business Practice Location Address:
SUITE 520
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-8122
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
458-205-6129
Provider Business Practice Location Address Fax Number:
458-205-6160
Provider Enumeration Date:
07/16/2010

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: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207N00000X , with the licence number: MD170325 , 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)





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