Basic Information
| Provider Information | |||||||||
| NPI: | 1245307693 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALEM PEDIATRIC CLINIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2478 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033622481 | ||||||||
| FaxNumber: | 5033717803 | ||||||||
| Practice Location | |||||||||
| Address1: | 2478 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033622481 | ||||||||
| FaxNumber: | 5033717803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 03/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | CASEBEER | ||||||||
| AuthorizedOfficialFirstName: | LIZ | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5034853707 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.