Provider Demographics
NPI:1295037968
Name:JAN RADZIK, MD PC
Entity Type:Organization
Organization Name:JAN RADZIK, MD PC
Other - Org Name:JAN RADZIK, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAN
Authorized Official - Middle Name:NONE
Authorized Official - Last Name:RADZIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:503-472-9438
Mailing Address - Street 1:349 SE BAKER ST
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-6039
Mailing Address - Country:US
Mailing Address - Phone:503-472-9438
Mailing Address - Fax:503-472-9439
Practice Address - Street 1:349 SE BAKER ST
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:OR
Practice Address - Zip Code:97128-6039
Practice Address - Country:US
Practice Address - Phone:503-472-9438
Practice Address - Fax:503-472-9439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD17050261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR029186Medicaid
ORC46223Medicare UPIN
OR107435Medicare PIN