1164810545 NPI number — NORTHWEST CANCER CARE ASSOCIATES PC

Table of content: DR. MATTHEW AUGUST ODENWALD MD (NPI 1720517816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164810545 NPI number — NORTHWEST CANCER CARE ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST CANCER CARE ASSOCIATES 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:
1164810545
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7379 W DESCHUTES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNEWICK
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99336-7900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-987-1800
Provider Business Mailing Address Fax Number:
509-987-1808

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7379 W DESCHUTES AVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
KENNEWICK
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99336-7900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-987-1800
Provider Business Practice Location Address Fax Number:
509-987-1808
Provider Enumeration Date:
01/07/2015

Additional Information

Authorized Official

Authorized Official Last Name:
SCHROADER
Authorized Official First Name:
MELISSA
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING SPECIALIST
Authorized Official Telephone Number:
602-932-8288

Provider Taxonomy Codes

  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1164810545 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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