Basic Information
Provider Information | |||||||||
NPI: | 1134382328 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATEL | ||||||||
FirstName: | BHARGAVBHAI | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | PATEL | ||||||||
OtherFirstName: | BHARGAV | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 1900 WOODLAND DR | ||||||||
Address2: |   | ||||||||
City: | COOS BAY | ||||||||
State: | OR | ||||||||
PostalCode: | 974202045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412675151 | ||||||||
FaxNumber: | 5412664542 | ||||||||
Practice Location | |||||||||
Address1: | 1900 WOODLAND DR | ||||||||
Address2: |   | ||||||||
City: | COOS BAY | ||||||||
State: | OR | ||||||||
PostalCode: | 974202045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412675151 | ||||||||
FaxNumber: | 5412664542 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2008 | ||||||||
LastUpdateDate: | 03/12/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | MD153959 | OR | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 161133 | 01 | OR | NBMC MAIM GROUP MEDCAID | OTHER | 39 | 01 | NJ | STUDENT AND EDUCATION | OTHER | 93-0635514 | 01 | OR | NBMC MAIN TAX ID FOR BILLING | OTHER | 1407812365 | 01 | OR | NBMC MAIN GROUP NPI | OTHER | 500636365 | 05 | OR |   | MEDICAID | R0000WFBTV | 01 | OR | NBMC MAIN GROUP MEDICARE | OTHER |