1992973622 NPI number — SALEM CLINIC, PC

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 1992973622 NPI number — SALEM CLINIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SALEM CLINIC, 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:
1992973622
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 8100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALEM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97303-0900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-399-2424
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5900 INLAND SHORES WAY N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEIZER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97303-3795
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-399-2424
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/15/2008

Additional Information

Authorized Official

Authorized Official Last Name:
GUNDER
Authorized Official First Name:
BARBARA
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR/CAO
Authorized Official Telephone Number:
503-399-2470

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CS4159 . This is a "RAILROAD MEDICARE NO." identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R0000WCJWK . This is a "MEDICARE PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500400276 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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