1851574594 NPI number — RICARDO B. EUSEBIO, M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851574594 NPI number — RICARDO B. EUSEBIO, M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICARDO B. EUSEBIO, M.D.
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:
Provider Other Organization Name Type Code:
6
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:
1851574594
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
633 GOVERNOR CARLOS CAMACHO ROAD
Provider Second Line Business Mailing Address:
STE. 202
Provider Business Mailing Address City Name:
TAMUNING
Provider Business Mailing Address State Name:
GU
Provider Business Mailing Address Postal Code:
96913-3143
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
671-646-0443
Provider Business Mailing Address Fax Number:
671-646-0440

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
GUAM MEDICAL PLAZA 633 GOVERNOR CARLOS CAMACHO ROAD
Provider Second Line Business Practice Location Address:
STE. 202
Provider Business Practice Location Address City Name:
TAMUNING
Provider Business Practice Location Address State Name:
GU
Provider Business Practice Location Address Postal Code:
96913-3143
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
671-646-0443
Provider Business Practice Location Address Fax Number:
671-646-0440
Provider Enumeration Date:
12/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
EUSEBIO
Authorized Official First Name:
RICARDO
Authorized Official Middle Name:
BROWNLEE
Authorized Official Title or Position:
SOLE PROPRIETOR
Authorized Official Telephone Number:
671-646-0443

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  M001017 , registered in the state of GU ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M001017 . This is a "GUAM MEDICAL LICENSE" identifier , issued by the state of ( GU ) . This identifiers is of the category "OTHER".
  • Identifier: 10-M1017A . This is a "GUAM CONTROLLED SUBSTANCE" identifier , issued by the state of ( GU ) . This identifiers is of the category "OTHER".
  • Identifier: 217 , issued by the state of ( GU ) . This identifiers is of the category "MEDICAID".




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