Basic Information
| Provider Information | |||||||||
| NPI: | 1043483886 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WILLAMETTE FAMILY MEDICAL CENTER, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LUCKIAMUTE CLINIC | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 MEDICAL CENTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973012762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035856388 | ||||||||
| FaxNumber: | 5034853951 | ||||||||
| Practice Location | |||||||||
| Address1: | 304 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | FALLS CITY | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973449793 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5037873353 | ||||||||
| FaxNumber: | 5037872911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2008 | ||||||||
| LastUpdateDate: | 04/11/2008 | ||||||||
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| AuthorizedOfficialLastName: | STEELE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5035856388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 230452 | 05 | OR | MEDICAID |