1962418905 NPI number — DAGAN ADAIR GREEN MS PT

Table of content: DAGAN ADAIR GREEN MS PT (NPI 1962418905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962418905 NPI number — DAGAN ADAIR GREEN MS PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREEN
Provider First Name:
DAGAN
Provider Middle Name:
ADAIR
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS PT
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:
1962418905
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11481 SW HALL BLVD
Provider Second Line Business Mailing Address:
SUITE 201
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-219-8835
Provider Business Mailing Address Fax Number:
503-639-9699

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
702 SW RAMSEY AVE
Provider Second Line Business Practice Location Address:
SUITE 220
Provider Business Practice Location Address City Name:
GRANTS PASS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97527-5858
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-479-0765
Provider Business Practice Location Address Fax Number:
541-479-3461
Provider Enumeration Date:
07/31/2006

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: 225100000X , with the licence number:  PT959 , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 6358 , 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: 116812600 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500626304 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00877705 . This is a "RR MEDICARE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com