1821078080 NPI number — BRENT B SAETRUM MD

Table of content: BRENT B SAETRUM MD (NPI 1821078080)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821078080 NPI number — BRENT B SAETRUM MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SAETRUM
Provider First Name:
BRENT
Provider Middle Name:
B
Provider Name Prefix Text:
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:
1821078080
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10184 NE GARIBALDI LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BAINBRIDGE ISLAND
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
98110
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
206-855-4778
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 HOPYARD ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PLEASANTON
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
94588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-251-6917
Provider Business Practice Location Address Fax Number:
925-924-0506
Provider Enumeration Date:
01/21/2006

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: 207P00000X , with the licence number:  K4994 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1164394-04 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8F9287 . This is a "BC/BS PROVIDER NUMBER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 930116427 . This is a "RAILROAD MEDICARE PROV #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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