1952305385 NPI number — DR. ELISE JAN FULSANG MD

Table of content: DR. ELISE JAN FULSANG MD (NPI 1952305385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952305385 NPI number — DR. ELISE JAN FULSANG MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULSANG
Provider First Name:
ELISE
Provider Middle Name:
JAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1952305385
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24800 SE STARK ST.
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRESHAM
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97030
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-674-1391
Provider Business Mailing Address Fax Number:
503-413-1895

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 N GRAHAM ST
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97227-1683
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-413-4134
Provider Business Practice Location Address Fax Number:
503-413-1895
Provider Enumeration Date:
06/13/2005

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: 207R00000X , with the licence number:  MD23553 , 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: 232402 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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