1316043979 NPI number — ROSEBURG CLINIC, P.C.

Table of content: (NPI 1316043979)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316043979 NPI number — ROSEBURG CLINIC, P.C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROSEBURG CLINIC, P.C.
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:
6
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:
1316043979
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/07/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2750 W HARVARD AVE
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:
97471-2608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-673-8988
Provider Business Mailing Address Fax Number:
541-672-8103

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
341 MEDICAL LOOP
Provider Second Line Business Practice Location Address:
STE 120
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-5546
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-673-8988
Provider Business Practice Location Address Fax Number:
541-672-8103
Provider Enumeration Date:
09/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
SEELY
Authorized Official First Name:
BRAD
Authorized Official Middle Name:
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
541-673-8988

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  MD17071 , 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)





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