1447223466 NPI number — NORTHWESTERN NEUROLOGICAL ASSOC PC

Table of content: (NPI 1447223466)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447223466 NPI number — NORTHWESTERN NEUROLOGICAL ASSOC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWESTERN NEUROLOGICAL ASSOC PC
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:
NORTHWESTERN NEUROLOGICAL ASSOCIATES PC
Provider Other Organization Name Type Code:
5
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:
1447223466
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/26/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 N GRAHAM ST
Provider Second Line Business Mailing Address:
SUITE 545
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97227-1654
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-288-5151
Provider Business Mailing Address Fax Number:
503-288-4942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
501 N GRAHAM ST
Provider Second Line Business Practice Location Address:
SUITE 545
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97227-1654
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-288-5151
Provider Business Practice Location Address Fax Number:
503-288-4942
Provider Enumeration Date:
02/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GREWE
Authorized Official First Name:
KENT
Authorized Official Middle Name:
MICHAEL
Authorized Official Title or Position:
PRESIDENT OF CORPORATION
Authorized Official Telephone Number:
503-288-5151

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 004197 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: R0000WCJVQ . This is a "PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 001782000 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".




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