1376589218 NPI number — PAUL D BLAYLOCK MD

Table of content: PAUL D BLAYLOCK MD (NPI 1376589218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376589218 NPI number — PAUL D BLAYLOCK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLAYLOCK
Provider First Name:
PAUL
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1376589218
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/02/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 13994
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:
97213-0994
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:
1881 NW 185TH AVE
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
ALOHA
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97006-6822
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-216-9360
Provider Business Practice Location Address Fax Number:
503-216-9363
Provider Enumeration Date:
06/21/2006

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: 207P00000X , with the licence number:  MD08602 , 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: P00208130 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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