Basic Information
| Provider Information | |||||||||
| NPI: | 1093828006 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SILVERTON HEALTH | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | LEGACY MEDICAL GROUP ORTHOPEDICS AND SPORTS MEDICINE SILVERTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3417 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038731500 | ||||||||
| FaxNumber: | 5038731534 | ||||||||
| Practice Location | |||||||||
| Address1: | 452 WELCH ST | ||||||||
| Address2: | |||||||||
| City: | SILVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038731722 | ||||||||
| FaxNumber: | 5038742470 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2006 | ||||||||
| LastUpdateDate: | 07/20/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JENSEN | ||||||||
| AuthorizedOfficialFirstName: | SARAH | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 5034155145 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | MD25349 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | MD16538 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | MD24813 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | MD25866 | OR | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 174400000X | 200550137NP | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.