1336596113 NPI number — AT HOME PRIMARY CARE

Table of content: (NPI 1336596113)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336596113 NPI number — AT HOME PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AT HOME PRIMARY CARE
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:
1336596113
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/20/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 945
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE OSWEGO
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97034-0103
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-344-6717
Provider Business Mailing Address Fax Number:
503-345-9867

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
511 MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 112
Provider Business Practice Location Address City Name:
OREGON CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97045-1830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-344-6717
Provider Business Practice Location Address Fax Number:
503-345-9867
Provider Enumeration Date:
05/20/2016

Additional Information

Authorized Official

Authorized Official Last Name:
FERGUSON
Authorized Official First Name:
MONICA
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
503-358-7908

Provider Taxonomy Codes

  • Taxonomy code: 363LP2300X , with the licence number:  200650008NP , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: 200650008NP , 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: 243056 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200650008NP . This is a "NP LICENSE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R178969 . This is a "MEDICARE ID INDIV" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1932154366 . This is a "NPI INDIV" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500678021 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1093053431 . This is a "NPI GROUP HMS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R178970 . This is a "MEDICARE ID GROUP" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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