1497051320 NPI number — NORTHWEST DIAGNOSTIC SERVICES

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497051320 NPI number — NORTHWEST DIAGNOSTIC SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHWEST DIAGNOSTIC SERVICES
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:
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:
1497051320
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2728 W MAIN ST
Provider Second Line Business Mailing Address:
SUITE 121
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97501-2499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-622-6088
Provider Business Mailing Address Fax Number:
541-622-6090

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2728 W MAIN ST
Provider Second Line Business Practice Location Address:
SUITE 121
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97501-2499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-622-6088
Provider Business Practice Location Address Fax Number:
541-622-6090
Provider Enumeration Date:
02/10/2011

Additional Information

Authorized Official

Authorized Official Last Name:
HETHERINGTON
Authorized Official First Name:
JANET
Authorized Official Middle Name:
Authorized Official Title or Position:
EXCECUTIVE MANAGER
Authorized Official Telephone Number:
541-622-6088

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  12-35846 , 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: R163709 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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