Basic Information
| Provider Information | |||||||||
| NPI: | 1043241581 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OREGON IMAGING CENTERS, L.L.C. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | OREGON IMAGING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416877134 | ||||||||
| FaxNumber: | 5413346144 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 HILYARD ST | ||||||||
| Address2: | #330 | ||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416877134 | ||||||||
| FaxNumber: | 5413346144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/07/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHALTRAW | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 5413347555 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | MBA | ||||||||
| NPICertificationDate: | 07/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 052964 | 05 | OR | MEDICAID |