1790905859 NPI number — UMPQUA VALLEY WOMENS CARE PC

Table of content: (NPI 1790905859)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790905859 NPI number — UMPQUA VALLEY WOMENS CARE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
UMPQUA VALLEY WOMENS CARE 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:
6
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:
1790905859
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2423 NW TROOST STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97470
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-464-0788
Provider Business Mailing Address Fax Number:
541-464-0789

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2423 NW TROOST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-1706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-464-0788
Provider Business Practice Location Address Fax Number:
541-464-0789
Provider Enumeration Date:
04/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VANNUCCI
Authorized Official First Name:
STEVEN
Authorized Official Middle Name:
JOEL
Authorized Official Title or Position:
COO/ CFO
Authorized Official Telephone Number:
541-464-0788

Provider Taxonomy Codes

  • Taxonomy code: 207VG0400X , with the licence number:  DO21702 , 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: 139406 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 067743001 . This is a "BLUE CROSS" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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