1285879676 NPI number — DR. EILEEN KERIN KILMARTIN MCCARTY M.D.

Table of content: DR. EILEEN KERIN KILMARTIN MCCARTY M.D. (NPI 1285879676)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285879676 NPI number — DR. EILEEN KERIN KILMARTIN MCCARTY M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MCCARTY
Provider First Name:
EILEEN
Provider Middle Name:
KERIN KILMARTIN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1285879676
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3158
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97208-3158
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-215-6494
Provider Business Mailing Address Fax Number:
503-215-6644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1500 DIVISION ST
Provider Second Line Business Practice Location Address:
1ST FLOOR
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1527
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-722-3705
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/13/2008

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: 2084P0804X , with the licence number:  MD29394 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: MD29394 , 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: 500624045 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500622223 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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