1861490831 NPI number — JEFFREY R OSWORTH PA

Table of content: JEFFREY R OSWORTH PA (NPI 1861490831)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861490831 NPI number — JEFFREY R OSWORTH PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSWORTH
Provider First Name:
JEFFREY
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1861490831
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1500 GADY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ADRIAN
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49221-9807
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-264-1922
Provider Business Mailing Address Fax Number:
517-263-6456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
770 RIVERSIDE AVE
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
ADRIAN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49221-1476
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-264-1922
Provider Business Practice Location Address Fax Number:
517-263-6456
Provider Enumeration Date:
07/13/2005

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: 363AM0700X , with the licence number:  50001098 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 5601002855 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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