Basic Information
| Provider Information | |||||||||
| NPI: | 1376995175 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIANS MEDICAL CENTER, P C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2435 NE CUMULUS AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971288805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034726161 | ||||||||
| FaxNumber: | 5034348498 | ||||||||
| Practice Location | |||||||||
| Address1: | 2435 NE CUMULUS AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | MCMINNVILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971288805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034726161 | ||||||||
| FaxNumber: | 5034348498 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2016 | ||||||||
| LastUpdateDate: | 09/12/2022 | ||||||||
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| AuthorizedOfficialLastName: | GRAY | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5034348285 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 09/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | 200040842RN | OR | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.