Basic Information
| Provider Information | |||||||||
| NPI: | 1871757823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROBERT A MAIRS DO PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ROBERT A MAIRS DO PC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1219 SW 4TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979144516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418892229 | ||||||||
| FaxNumber: | 5418890716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1219 SW 4TH AVE | ||||||||
| Address2: | SUITE 2 | ||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979144516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418892229 | ||||||||
| FaxNumber: | 5418890716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2008 | ||||||||
| LastUpdateDate: | 01/04/2013 | ||||||||
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| AuthorizedOfficialLastName: | MAIRS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5418892229 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DO | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | DO20644 | OR | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 150184 | 05 | OR | MEDICAID |