1801180815 NPI number — DR. MARY ANN GALAGATE MUTH D.O.

Table of content: DR. MARY ANN GALAGATE MUTH D.O. (NPI 1801180815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801180815 NPI number — DR. MARY ANN GALAGATE MUTH D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MUTH
Provider First Name:
MARY ANN
Provider Middle Name:
GALAGATE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GALAGATE
Provider Other First Name:
MARY ANN
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DO
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801180815
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
619 NW 6TH AVE FL 5
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97209-3964
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
503-988-3015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
600 NE 8TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-7317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-988-5155
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/07/2011

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: 207Q00000X , with the licence number:  OL60231724 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 096511 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 22959 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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