1013908508 NPI number — AAILEEN SUE CARMELL MS

Table of content: AAILEEN SUE CARMELL MS (NPI 1013908508)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013908508 NPI number — AAILEEN SUE CARMELL MS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARMELL
Provider First Name:
AAILEEN
Provider Middle Name:
SUE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS
Provider Gender Code:
F

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:
1013908508
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1776 SW MADISON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97205-1715
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-621-1069
Provider Business Mailing Address Fax Number:
503-621-0200

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
808 SW ALDER ST
Provider Second Line Business Practice Location Address:
STE 300
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97205-3133
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-226-2203
Provider Business Practice Location Address Fax Number:
503-223-4231
Provider Enumeration Date:
11/02/2005

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: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 126370 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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