1346297793 NPI number — DR. JOSEPH LOUIS PETRUSEK M.D., P.C.

Table of content: DR. JOSEPH LOUIS PETRUSEK M.D., P.C. (NPI 1346297793)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346297793 NPI number — DR. JOSEPH LOUIS PETRUSEK M.D., P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETRUSEK
Provider First Name:
JOSEPH
Provider Middle Name:
LOUIS
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D., P.C.
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:
1346297793
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1123
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA GRANDE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97850-6123
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-963-8643
Provider Business Mailing Address Fax Number:
541-963-5845

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 SUNSET DR
Provider Second Line Business Practice Location Address:
STE. D
Provider Business Practice Location Address City Name:
LA GRANDE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97850-1200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-963-8643
Provider Business Practice Location Address Fax Number:
541-963-5845
Provider Enumeration Date:
05/30/2006

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: 207Y00000X , with the licence number:  MD09444 , 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: 009100000 . This is a "BLUE CROSS PROVIDER NUMBE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 041913293 . This is a "RAILROAD MEDICARE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 161026 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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