1447236021 NPI number — ALLISON WHITESIDE PT

Table of content: ALLISON WHITESIDE PT (NPI 1447236021)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447236021 NPI number — ALLISON WHITESIDE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHITESIDE
Provider First Name:
ALLISON
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1447236021
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9380 NE WORDEN HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DUNDEE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97115-9146
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-538-9821
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
403 SW DENNIS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HILLSBORO
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97123-3928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-640-3803
Provider Business Practice Location Address Fax Number:
503-640-3805
Provider Enumeration Date:
12/15/2005

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: 174400000X , with the licence number:  4588 , 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: 276348 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8383510000 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".