1164978771 NPI number — AUDREY ROBINSON

Table of content: AUDREY ROBINSON (NPI 1164978771)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164978771 NPI number — AUDREY ROBINSON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ROBINSON
Provider First Name:
AUDREY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1164978771
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/23/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3028 SW 153RD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BEAVERTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97003-5116
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 SPRING ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTBROOK
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04092-3915
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-856-1230
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2016

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: 225100000X , with the licence number:  PT4654 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: W183304560 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".




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