Basic Information
| Provider Information | |||||||||
| NPI: | 1386087831 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | APP THREE RIVERS MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 748157 | ||||||||
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| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900748157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417895250 | ||||||||
| FaxNumber: | 5417895538 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 SW RAMSEY AVE | ||||||||
| Address2: | |||||||||
| City: | GRANTS PASS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975275554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414727000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 04/15/2013 | ||||||||
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| AuthorizedOfficialLastName: | HARVEY | ||||||||
| AuthorizedOfficialFirstName: | STEFAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5417895190 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ASANTE PHYSICIAN PARTNER | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant | 208M00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.