Basic Information
| Provider Information | |||||||||
| NPI: | 1255393419 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ASHLAND EMERGENCY ASSOCIATES, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1995 TOLMAN CREEK ROAD | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975203697 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414880679 | ||||||||
| FaxNumber: | 5415529690 | ||||||||
| Practice Location | |||||||||
| Address1: | 280 MAPLE ST | ||||||||
| Address2: | |||||||||
| City: | ASHLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975201552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034822441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 07/18/2015 | ||||||||
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| AuthorizedOfficialLastName: | ENNS | ||||||||
| AuthorizedOfficialFirstName: | GORDON | ||||||||
| AuthorizedOfficialMiddleName: | LEE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/AUTHORIZED GROUP REPRESEN | ||||||||
| AuthorizedOfficialTelephone: | 5414880679 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7094626 | 05 | WA | MEDICAID | XGG007121 | 01 | MEDI CAL | OTHER | 38D0969470 | 01 | CLIA WAIVER | OTHER | CF8926 | 01 | RAILROAD MEDICARE | OTHER | 059936 | 05 | OR | MEDICAID | 139457 | 05 | OR | MEDICAID | 023507000 | 01 | OR | BC/BS OF OREGON | OTHER | 126727 | 01 | WASHINGTON LABOR AND INDU | OTHER | 453217001 | 01 | GROUP HEALTH | OTHER |