1447474945 NPI number — DR. STEPHANIE A RICCALARSEN MD

Table of content: DR. STEPHANIE A RICCALARSEN MD (NPI 1447474945)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447474945 NPI number — DR. STEPHANIE A RICCALARSEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICCALARSEN
Provider First Name:
STEPHANIE
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1447474945
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2570 NW EDENBOWER BLVD.
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-6214
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-677-7200
Provider Business Mailing Address Fax Number:
541-229-3309

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2570 NW EDENBOWER BLVD.
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-6214
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-677-7200
Provider Business Practice Location Address Fax Number:
541-229-3309
Provider Enumeration Date:
04/13/2007

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: 207Q00000X , with the licence number:  5415 , registered in the state of NE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MD126056 , 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: 0577260001 . This is a "GROUP DMERC" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 161133 . This is a "GROUP DMAP - OREGON MEDICAID" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1407812365 . This is a "GROUP NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: R0000WFBTV . This is a "GROUP MEDICARE NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500612601 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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