1215999321 NPI number — KATHLEEN M FITZGERALD MD

Table of content: KATHLEEN M FITZGERALD MD (NPI 1215999321)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215999321 NPI number — KATHLEEN M FITZGERALD MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
KATHLEEN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1215999321
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/17/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
330 SOUTH GARDEN WAY
Provider Second Line Business Mailing Address:
SUITE 270
Provider Business Mailing Address City Name:
EUGENE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97401
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-228-3400
Provider Business Mailing Address Fax Number:
541-284-2937

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
330 S GARDEN WAY
Provider Second Line Business Practice Location Address:
SUITE 270
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-8176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-228-3400
Provider Business Practice Location Address Fax Number:
541-284-2937
Provider Enumeration Date:
04/04/2006

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: 174400000X , with the licence number:  MD17475 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: MD17475 , 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: P00429041 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 2329 . This is a "LIPA" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 033345 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 085564000 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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