1265857627 NPI number — SANDRA J. KRUSSEL, DO, PSYCHIATRIST, LLC

Table of content: (NPI 1265857627)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265857627 NPI number — SANDRA J. KRUSSEL, DO, PSYCHIATRIST, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SANDRA J. KRUSSEL, DO, PSYCHIATRIST, LLC
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:
SANDRA J. KRUSSEL, DO
Provider Other Organization Name Type Code:
3
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:
1265857627
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/22/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2250 NW FLANDERS ST
Provider Second Line Business Mailing Address:
SUITE 306
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97210-3443
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-226-0558
Provider Business Mailing Address Fax Number:
503-276-1284

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2250 NW FLANDERS ST
Provider Second Line Business Practice Location Address:
306
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-3443
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-226-0558
Provider Business Practice Location Address Fax Number:
503-276-1284
Provider Enumeration Date:
02/21/2014

Additional Information

Authorized Official

Authorized Official Last Name:
KRUSSEL
Authorized Official First Name:
SANDRA
Authorized Official Middle Name:
JANE
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
503-226-0558

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  DO152642 , 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)





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