Basic Information
| Provider Information | |||||||||
| NPI: | 1073511721 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ROGUE COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 19 MYRTLE STREET | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417733863 | ||||||||
| FaxNumber: | 5417762892 | ||||||||
| Practice Location | |||||||||
| Address1: | 19 MYRTLE STREET | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975047337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417733863 | ||||||||
| FaxNumber: | 5417762892 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARNKE | ||||||||
| AuthorizedOfficialFirstName: | CALISA | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5418427642 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 227698 | 05 | OR | MEDICAID |