1700335536 NPI number — JOEL M SUCKOW-MD, LLC

Table of content: (NPI 1700335536)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700335536 NPI number — JOEL M SUCKOW-MD, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JOEL M SUCKOW-MD, LLC
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:
1700335536
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
773 LINDA AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEIZER
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97303-4549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-585-7454
Provider Business Mailing Address Fax Number:
888-256-7959

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
773 LINDA AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KEIZER
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97303-4549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-808-2854
Provider Business Practice Location Address Fax Number:
888-256-7959
Provider Enumeration Date:
09/21/2016

Additional Information

Authorized Official

Authorized Official Last Name:
GONZALEZ
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALING MANAGER
Authorized Official Telephone Number:
541-941-7792

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  OR MD28195 , 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: OR MD28195 . This is a "OREGON STATE LICNESE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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