Healthcare Provider Details

I. General information

NPI: 1215999321
Provider Name (Legal Business Name): KATHLEEN M FITZGERALD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 11/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 S GARDEN WAY SUITE 270
EUGENE OR
97401-8176
US

IV. Provider business mailing address

330 SOUTH GARDEN WAY SUITE 270
EUGENE OR
97401
US

V. Phone/Fax

Practice location:
  • Phone: 541-228-3400
  • Fax: 541-284-2937
Mailing address:
  • Phone: 541-228-3400
  • Fax: 541-284-2937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberMD17475
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD17475
License Number StateOR

VII. Legacy identifiers

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

# 1
IdentifierP00429041
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerRAILROAD MEDICARE
# 2
Identifier2329
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerLIPA
# 3
Identifier033345
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 4
Identifier085564000
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerBLUE CROSS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: