1902067010 NPI number — URGENTCARE NW-ASTORIA PC

Table of content: (NPI 1902067010)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902067010 NPI number — URGENTCARE NW-ASTORIA PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
URGENTCARE NW-ASTORIA PC
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:
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:
1902067010
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 96
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BORING
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-577-8410
Provider Business Mailing Address Fax Number:
503-325-6333

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2120 EXCHANGE ST
Provider Second Line Business Practice Location Address:
SUITE 111
Provider Business Practice Location Address City Name:
ASTORIA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97103-3366
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-325-0333
Provider Business Practice Location Address Fax Number:
503-325-6333
Provider Enumeration Date:
06/20/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KLATT
Authorized Official First Name:
MARY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHIEF OPERATIONS OFFICER
Authorized Official Telephone Number:
503-325-0333

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QU0200X , with the licence number: 1351854-3 , 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: 246578 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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