1780661371 NPI number — DR. BRUCE RANDOLPH WEBBER MD

Table of content: DR. BRUCE RANDOLPH WEBBER MD (NPI 1780661371)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780661371 NPI number — DR. BRUCE RANDOLPH WEBBER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEBBER
Provider First Name:
BRUCE
Provider Middle Name:
RANDOLPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1780661371
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/25/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
847 NE 19TH AVE
Provider Second Line Business Mailing Address:
SUITE 300
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97232-2684
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-963-2801
Provider Business Mailing Address Fax Number:
503-963-2825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9155 SW BARNES RD
Provider Second Line Business Practice Location Address:
STE 532
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97225
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-488-2344
Provider Business Practice Location Address Fax Number:
503-488-2360
Provider Enumeration Date:
12/27/2005

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: 208200000X , with the licence number:  MD 12636 , 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: 154906 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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