Basic Information
| Provider Information | |||||||||
| NPI: | 1306191044 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SILVERTON HEALTH | ||||||||
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| OtherOrganizationName: | LEGACY MEDICAL GROUP SILVERTON | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4037 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038731500 | ||||||||
| FaxNumber: | 5038731534 | ||||||||
| Practice Location | |||||||||
| Address1: | 347 FAIRVIEW ST | ||||||||
| Address2: | |||||||||
| City: | SILVERTON | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038735667 | ||||||||
| FaxNumber: | 5038735687 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 10/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | HOFF | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5034155730 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.