1629088646 NPI number — MRS. ELLEN ROE CRAIG MPT

Table of content: MRS. ELLEN ROE CRAIG MPT (NPI 1629088646)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629088646 NPI number — MRS. ELLEN ROE CRAIG MPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CRAIG
Provider First Name:
ELLEN
Provider Middle Name:
ROE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MPT
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:
1629088646
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
91 BUCKBOARD RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWCASTLE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95658-9431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-663-3573
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2945 BELL ROAD
Provider Second Line Business Practice Location Address:
#215
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95603
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-367-1888
Provider Business Practice Location Address Fax Number:
530-888-0885
Provider Enumeration Date:
08/09/2006

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: 225100000X , with the licence number:  OPT16260 ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: ZZZ08443Z . This is a "BLUE SHIELD" identifier . This identifiers is of the category "OTHER".




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