1295037968 NPI number — JAN RADZIK, MD PC

Table of content: (NPI 1295037968)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295037968 NPI number — JAN RADZIK, MD PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JAN RADZIK, MD 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:
JAN RADZIK, MD
Provider Other Organization Name Type Code:
5
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:
1295037968
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/01/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
349 SE BAKER ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCMINNVILLE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97128-6039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-472-9438
Provider Business Mailing Address Fax Number:
503-472-9439

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
349 SE BAKER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MCMINNVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97128-6039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-472-9438
Provider Business Practice Location Address Fax Number:
503-472-9439
Provider Enumeration Date:
12/01/2010

Additional Information

Authorized Official

Authorized Official Last Name:
RADZIK
Authorized Official First Name:
JAN
Authorized Official Middle Name:
NONE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-472-9438

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  MD17050 , 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: 029186 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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