Provider Demographics
NPI:1164535985
Name:KASIA VAN PETT, MD, PC
Entity Type:Organization
Organization Name:KASIA VAN PETT, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:COMSTOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:541-686-3791
Mailing Address - Street 1:74B CENTENNIAL LOOP
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7918
Mailing Address - Country:US
Mailing Address - Phone:541-686-3791
Mailing Address - Fax:541-686-3795
Practice Address - Street 1:74B CENTENNIAL LOOP
Practice Address - Street 2:SUITE 100
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7918
Practice Address - Country:US
Practice Address - Phone:541-686-3791
Practice Address - Fax:541-686-3795
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NEUROSPINE INSTITUTE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-16
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR150130Medicaid
ORG49443Medicare UPIN
OR150130Medicaid