Provider Demographics
NPI:1851107635
Name:SIRCHUK, EDWARD FRAZIER SR
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:FRAZIER
Last Name:SIRCHUK
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:GENERAL DELIVERY
Mailing Address - Street 2:
Mailing Address - City:HARBOR
Mailing Address - State:OR
Mailing Address - Zip Code:97415-9999
Mailing Address - Country:US
Mailing Address - Phone:541-813-9142
Mailing Address - Fax:
Practice Address - Street 1:15957 HIGHWAY 101 S STE 11
Practice Address - Street 2:
Practice Address - City:HARBOR
Practice Address - State:OR
Practice Address - Zip Code:97415-8507
Practice Address - Country:US
Practice Address - Phone:541-813-9142
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-06
Last Update Date:2024-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization