1902978984 NPI number — SURGICAL SPECIALTY GROUP PC

Table of content: MR. WALTER JOHN KELLY JR. MSW (NPI 1518105832)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902978984 NPI number — SURGICAL SPECIALTY GROUP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SURGICAL SPECIALTY GROUP 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:
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:
1902978984
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/05/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
511 SW 10TH AVENUE
Provider Second Line Business Mailing Address:
SUITE 714
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97205-2708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-222-1615
Provider Business Mailing Address Fax Number:
503-222-0016

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 SW 10TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE 714
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97205-2708
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-222-1615
Provider Business Practice Location Address Fax Number:
503-222-0016
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VEIS
Authorized Official First Name:
OLGA
Authorized Official Middle Name:
MARIA
Authorized Official Title or Position:
CLINIC MANAGER
Authorized Official Telephone Number:
503-222-1615

Provider Taxonomy Codes

  • Taxonomy code: 261QM2500X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 084061 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 001783700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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