1083745038 NPI number — TWO RIVERS CLINIC

Table of content: DR. AGU NMN SUVARI M.D. (NPI 1336267897)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083745038 NPI number — TWO RIVERS CLINIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TWO RIVERS CLINIC
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:
1083745038
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1941 POTTER STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401-3059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-485-9534
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
995 WILLAGILLESPIE, STE 200A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-484-4339
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
STOUT
Authorized Official First Name:
JONATHAN
Authorized Official Middle Name:
BRUCE
Authorized Official Title or Position:
OWNER-PHYSICIAN
Authorized Official Telephone Number:
541-484-4339

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD15846 , 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: 027565 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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