Healthcare Provider Details

I. General information

NPI: 1780663609
Provider Name (Legal Business Name): HENRY ANDREW IRVINE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63245 SILVIS RD
BEND OR
97701-9743
US

IV. Provider business mailing address

63245 SILVIS RD
BEND OR
97701-9743
US

V. Phone/Fax

Practice location:
  • Phone: 458-206-0145
  • Fax:
Mailing address:
  • Phone: 458-206-0145
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0101235094
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101235094
License Number StateVA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier127605
Identifier TypeOTHER
Identifier StateFL
Identifier IssuerLICENSE
# 2
Identifier024499500
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: