1518906247 NPI number — DR. GARY HALVORSON M.D.

Table of content: DR. GARY HALVORSON M.D. (NPI 1518906247)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518906247 NPI number — DR. GARY HALVORSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HALVORSON
Provider First Name:
GARY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
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:
1518906247
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4078
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:
97208-4078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
888-633-0086
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1255 HILYARD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EUGENE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97401-3718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-686-7300
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/06/2006

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: 207P00000X , with the licence number:  MD15445 , 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: 76328 . This is a "WASHINGTON L&I" identifier . This identifiers is of the category "OTHER".
  • Identifier: C92795 . This is a "PROVIDENCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: J0475-06 . This is a "PACIFIC SOURCE" identifier . This identifiers is of the category "OTHER".
  • Identifier: XPY185060 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 195404 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: A015 . This is a "CHAMPUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: C92795 . This is a "GROUP HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8280042 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: C92795 . This is a "LIPA" identifier . This identifiers is of the category "OTHER".




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