Basic Information
Provider Information | |||||||||
NPI: | 1538121769 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROSTYKUS | ||||||||
FirstName: | PAUL | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 34935 | ||||||||
Address2: | DEPARTMENT 563 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 981241935 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8886330079 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 280 MAPLE ST | ||||||||
Address2: |   | ||||||||
City: | ASHLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 975201552 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5412014100 | ||||||||
FaxNumber: | 5414887434 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2006 | ||||||||
LastUpdateDate: | 02/21/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD15433 | OR | Y |   | Allopathic & Osteopathic Physicians | Emergency Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 97520A006 | 01 |   | CHAMPUS | OTHER | B42699 | 01 |   | GROUP HEALTH | OTHER | 023507000 | 01 |   | BC/BS OF OREGON | OTHER | 170084 | 05 | OR |   | MEDICAID | 930079052 | 01 |   | RAILROAD MEDICARE | OTHER | B42699 | 01 |   | PROVIDENCE HEALTH PLAN | OTHER | XPY185097 | 01 |   | MEDI CAL | OTHER |