1447471990 NPI number — ROSEBURG FAMILY MEDICINE

Table of content: (NPI 1447471990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447471990 NPI number — ROSEBURG FAMILY MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSEBURG FAMILY MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447471990
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
340 NW MEDICAL LOOP
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-1645
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-677-6599
Provider Business Mailing Address Fax Number:
541-677-6576

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
340 NW MEDICAL LOOP
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-677-6599
Provider Business Practice Location Address Fax Number:
541-677-6576
Provider Enumeration Date:
05/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
KEYS
Authorized Official First Name:
CLYDE
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
541-677-6599

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  MD18437 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R0000WCYBS . This is a "IDENTIFICATION NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com