Basic Information
| Provider Information | |||||||||
| NPI: | 1932866860 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST ALPHONSUS PROFESSIONAL MEDICAL SERVICES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 357 | ||||||||
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| City: | COLCHESTER | ||||||||
| State: | IL | ||||||||
| PostalCode: | 62326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2084728185 | ||||||||
| FaxNumber: | 2084728172 | ||||||||
| Practice Location | |||||||||
| Address1: | 351 SW NINTH STREET | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | OR | ||||||||
| PostalCode: | 979142639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418815331 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2021 | ||||||||
| LastUpdateDate: | 11/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | RYSENGA | ||||||||
| AuthorizedOfficialFirstName: | ERIC | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | PATHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 5418817287 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 11/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.