Basic Information
| Provider Information | |||||||||
| NPI: | 1215999321 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FITZGERALD | ||||||||
| FirstName: | KATHLEEN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 330 SOUTH GARDEN WAY | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412283400 | ||||||||
| FaxNumber: | 5412842937 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 S GARDEN WAY | ||||||||
| Address2: | SUITE 270 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974018176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412283400 | ||||||||
| FaxNumber: | 5412842937 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD17475 | OR | N | Other Service Providers | Specialist | 2084N0400X | MD17475 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | P00429041 | 01 | OR | RAILROAD MEDICARE | OTHER | 2329 | 01 | OR | LIPA | OTHER | 033345 | 05 | OR | MEDICAID | 085564000 | 01 | OR | BLUE CROSS | OTHER |