1629051776 NPI number — DR. RORY FLEMING RICHARDSON PH.D., FICPPM

Table of content: DR. RORY FLEMING RICHARDSON PH.D., FICPPM (NPI 1629051776)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629051776 NPI number — DR. RORY FLEMING RICHARDSON PH.D., FICPPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RICHARDSON
Provider First Name:
RORY
Provider Middle Name:
FLEMING
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D., FICPPM
Provider Gender Code:
M

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:
1629051776
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 109
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLN CITY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97367-0109
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-994-4462
Provider Business Mailing Address Fax Number:
541-994-6329

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4466 NE DEVILS LAKE BLVD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
LINCOLN CITY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97367-5197
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-994-4462
Provider Business Practice Location Address Fax Number:
541-994-6329
Provider Enumeration Date:
11/22/2005

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: 101YM0800X , with the licence number:  C0068 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103G00000X , with the licence number: 1249 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 103T00000X , with the licence number: 1249 , 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: 092951 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: R 7WBQ0 . This is a "PACC HMO" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: OR00543 . This is a "MEDICARE NORIDIAN EDI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 069078000 . This is a "REGENCE BLUE CROSS BLUE S" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 171641 . This is a "MENTAL HEALTH NETWORK" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 150576 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 090021822 . This is a "STATE OF OREGON DDS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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