1518171339 NPI number — INTERNAL MEDICINE & GERIATRICS, P.C.

Table of content: (NPI 1518171339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518171339 NPI number — INTERNAL MEDICINE & GERIATRICS, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTERNAL MEDICINE & GERIATRICS, P.C.
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:
1518171339
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/21/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3369 NE STEPHENS ST.
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-677-8900
Provider Business Mailing Address Fax Number:
541-677-8903

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3369 NE STEPHENS ST.
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97470
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-677-8900
Provider Business Practice Location Address Fax Number:
541-677-8900
Provider Enumeration Date:
05/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RAJENDRAN
Authorized Official First Name:
RANGANATHAN
Authorized Official Middle Name:
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
541-677-8900

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  24877 , 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: 029057 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com