1821035841 NPI number — PHYSICIANS MEDICAL CENTER, P C

Table of content: (NPI 1821035841)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821035841 NPI number — PHYSICIANS MEDICAL CENTER, P C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS MEDICAL CENTER, P C
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:
PHYSICIANS MEDICAL CENTER, LAB
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:
1821035841
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2435 NE CUMULUS AVE STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCMINNVILLE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97128-8862
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-472-6161
Provider Business Mailing Address Fax Number:
503-434-8498

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2435 NE CUMULUS AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-8862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-472-6161
Provider Business Practice Location Address Fax Number:
503-434-8498
Provider Enumeration Date:
05/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
CRAIG
Authorized Official First Name:
KATHY
Authorized Official Middle Name:
J
Authorized Official Title or Position:
CREDENTIALING
Authorized Official Telephone Number:
503-758-4135

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  38D0622888 , 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)

  • Identifier: 38D0622888 . This is a "CLIA# MEDICARE/MEDICAID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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