1275544983 NPI number — GERALD R POFF M.P.T

Table of content: DR. ASTRIDE ROMELUS (NPI 1487936399)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275544983 NPI number — GERALD R POFF M.P.T

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POFF
Provider First Name:
GERALD
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.P.T
Provider Gender Code:
M

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:
1275544983
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1209 E EDISON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SUNNYSIDE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98944-2213
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-837-2528
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
211 EUCLID RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRANDVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98930-1160
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-882-7888
Provider Business Practice Location Address Fax Number:
509-882-6588
Provider Enumeration Date:
08/10/2006

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: 225100000X , with the licence number:  PT00003635 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2626PO . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 8424681 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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