Healthcare Provider Details

I. General information

NPI: 1578741427
Provider Name (Legal Business Name): SEASIDE URGENT CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2008
Last Update Date: 02/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 AVENUE U
SEASIDE OR
97138-5065
US

IV. Provider business mailing address

580 AVENUE U
SEASIDE OR
97138-5065
US

V. Phone/Fax

Practice location:
  • Phone: 503-738-9112
  • Fax:
Mailing address:
  • Phone: 503-738-9112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License NumberMD19990
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier029026
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer
# 2
Identifier130263
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name: JOANN STEFANELLI
Title or Position: PRACTICE MANAGER
Credential:
Phone: 503-738-9112