| NPI |
1568795946 |
The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number. |
| Entity Type Code |
2 |
Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual
human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO). |
| Employer Identification Number EIN |
|
The Employer Identification Number (EIN), assigned by the IRS, of the provider being identified. |
| Provider Organization Name Legal Business Name |
STARK MEDICAL DIAGNOSTIC CENTER, INC |
The date the provider was assigned a unique identifier (assigned an NPI). |
| Provider First Line Business Practice Location Address |
13232 SE STARK ST |
The date that a record was last updated or changed. |
| Provider Business Practice Location Address City Name |
PORTLAND |
The code designating the provider’s gender if the provider is a person. |
| Provider Business Practice Location Address State Name |
OR |
The State code in the location of the provider
being identified. |
| Provider Business Practice Location Address Postal Code |
972331573 |
The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. |
| Provider Business Practice Location Address Country Code If outside U S |
US |
The country code in the location address of the provider being identified. |
| Provider Business Practice Location Address Telephone Number |
5034087578 |
The telephone number associated with the location address of the provider being identified. |
| Provider Business Practice Location Address Fax Number |
5034087615 |
The fax number associated with the location
address of the provider being identified. |
| Provider Enumeration Date |
9/16/2009 |
Code indicating whether the provider is operating as a sole proprietor. Codes are: Y = Yes; N = No |
| Last Update Date |
9/16/2009 |
The date that a record was last updated or changed. |
| Authorized Official Last Name |
MACIAS |
The last name of the person authorized to submit the NPI application or to change NPS data for a health care provider. |
| Authorized Official First Name |
JORGE |
The first name of the authorized official. |
| Authorized Official Title or Position |
SECRETARY |
The title or position of the authorized official. |
| Authorized Official Telephone Number |
5034087578 |
The 10-position telephone number of the authorized official. |
| Healthcare Provider Taxonomy Code 1 |
171W00000X |
Code designating the provider type, classification,
and specialization. Codes are from the Healthcare Provider Taxonomy code list. The NPS will associate these data with the license data for providers with Entity type code = 1. |
| Healthcare Provider Primary Taxonomy Switch 1 |
Y |
|
| Is Organization Subpart |
N |
|
| Authorized Official Name Prefix Text |
MR. |
|
| Healthcare Provider Taxonomy Group 1 |
193400000X SINGLE SPECIALTY GROUP |
|