1841246048 NPI number — LISA A BRANDENBURGER MD

Table of content: LISA A BRANDENBURGER MD (NPI 1841246048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1841246048 NPI number — LISA A BRANDENBURGER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRANDENBURGER
Provider First Name:
LISA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1841246048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2750 W HARVARD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-673-8988
Provider Business Mailing Address Fax Number:
541-672-8103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2564 NW EDENBOWER BLVD
Provider Second Line Business Practice Location Address:
SUITE 126
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-8821
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-673-2223
Provider Business Practice Location Address Fax Number:
541-672-5828
Provider Enumeration Date:
05/26/2006

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: 207RG0100X , with the licence number:  MD26928 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RH0000X , with the licence number: MD26928 , 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: 006006 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com