Basic Information
Provider Information | |||||||||
NPI: | 1598776221 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHEASTERN RURAL HEALTH CLINICS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1850 SPRING RIDGE DR | ||||||||
Address2: |   | ||||||||
City: | SUSANVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 961306100 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302575563 | ||||||||
FaxNumber: | 5302576015 | ||||||||
Practice Location | |||||||||
Address1: | 436 435 OLD HIGHWAY RD | ||||||||
Address2: |   | ||||||||
City: | DOYLE | ||||||||
State: | CA | ||||||||
PostalCode: | 96109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5302575563 | ||||||||
FaxNumber: | 5302576015 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/10/2006 | ||||||||
LastUpdateDate: | 12/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | SCHAUB | ||||||||
AuthorizedOfficialFirstName: | MICHAEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 5302515000 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | DOYLE FAMILY PRACTICE | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | FHC03843F | 05 | CA |   | MEDICAID | ZZZ42576Z | 01 |   | BLUE SHIELD | OTHER |