1154662849 NPI number — SEAN L STEWARD, MD, PC

Table of content: (NPI 1154662849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154662849 NPI number — SEAN L STEWARD, MD, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SEAN L STEWARD, MD, 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:
GENEVA HEALTH CENTERS
Provider Other Organization Name Type Code:
3
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:
1154662849
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/06/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3838 PACIFIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FOREST GROVE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97116-2224
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-992-0288
Provider Business Mailing Address Fax Number:
503-359-4724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3838 PACIFIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FOREST GROVE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97116-2224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-992-0288
Provider Business Practice Location Address Fax Number:
503-359-4724
Provider Enumeration Date:
03/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
GORMAN-STEWARD
Authorized Official First Name:
THERESE
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
503-992-0288

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  260204-95 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X , with the licence number: 12202-001 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 085204 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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