Basic Information
| Provider Information | |||||||||
| NPI: | 1376673467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROLLINGS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 236 REES HILL RD SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973069111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035852303 | ||||||||
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| Practice Location | |||||||||
| Address1: | 435 LANCASTER DR NE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973014729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035856388 | ||||||||
| FaxNumber: | 5035850669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 02/17/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 12174 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 066498 | 05 | OR | MEDICAID | M4003 01 | 01 | OR | PACIFIC SOURCE | OTHER | 0057325873360 | 01 | OR | REGENCE BCBS OF OREGON | OTHER | 0169990022 | 01 | OR | PROVIDENCE HEALTH PLANS | OTHER |