1528366986 NPI number — PEDIATRIC CARDIOLOGY CENTER OF OREGON PC

Table of content: (NPI 1528366986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528366986 NPI number — PEDIATRIC CARDIOLOGY CENTER OF OREGON PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PEDIATRIC CARDIOLOGY CENTER OF OREGON PC
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:
1528366986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 821350
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98682-0030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-667-3049
Provider Business Mailing Address Fax Number:
360-666-0466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
971 11TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98632-2503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-667-3049
Provider Business Practice Location Address Fax Number:
360-666-0466
Provider Enumeration Date:
03/09/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LAMB
Authorized Official First Name:
AMANDA
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
BUSINESS ADMINISTRATOR
Authorized Official Telephone Number:
503-280-3418

Provider Taxonomy Codes

  • Taxonomy code: 2080P0202X , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2080P0202X , with the licence number: MD00026664 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 057775000 . This is a "REGENCE BLUE CROSS BLUE SHIELD OF OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 231812 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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