1942552062 NPI number — RICHARD S POLIN PC

Table of content: (NPI 1942552062)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942552062 NPI number — RICHARD S POLIN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD S POLIN 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:
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:
1942552062
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 25714
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:
97298-0714
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-666-8139
Provider Business Mailing Address Fax Number:
503-666-3434

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24900 SE STARK ST
Provider Second Line Business Practice Location Address:
SUITE 208
Provider Business Practice Location Address City Name:
GRESHAM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97030-3355
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-666-8139
Provider Business Practice Location Address Fax Number:
503-666-3434
Provider Enumeration Date:
10/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
POLIN
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
SANDERS
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
503-666-8149

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  MD 25930 , 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: 1043373996 . This is a "INDIVIDUAL NPI" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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