Basic Information
| Provider Information | |||||||||
| NPI: | 1356403455 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELDER | ||||||||
| FirstName: | HENRY | ||||||||
| MiddleName: | IRWIN | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1255 PEARL ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416876983 | ||||||||
| FaxNumber: | 5416847638 | ||||||||
| Practice Location | |||||||||
| Address1: | 1255 PEARL ST | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974013570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416876983 | ||||||||
| FaxNumber: | 5416847638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 06/23/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD 12543 | OR | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0805X | 12543 | OR | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 237750 | 05 | OR | MEDICAID |