1467478164 NPI number — DR. ELLEN J HALVERSON M.D.

Table of content: DR. ELLEN J HALVERSON M.D. (NPI 1467478164)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467478164 NPI number — DR. ELLEN J HALVERSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALVERSON
Provider First Name:
ELLEN
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1467478164
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4105
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:
97208-4105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-907-1068
Provider Business Mailing Address Fax Number:
425-917-9141

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 S WOODWORTH LOOP
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
PALMER
Provider Business Practice Location Address State Name:
AK
Provider Business Practice Location Address Postal Code:
99645-7412
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
907-761-5800
Provider Business Practice Location Address Fax Number:
907-761-5801
Provider Enumeration Date:
07/14/2006

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: 2084P0800X , with the licence number:  4152 , registered in the state of AK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1010614 , issued by the state of ( AK ) . This identifiers is of the category "MEDICAID".




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