Basic Information
| Provider Information | |||||||||
| NPI: | 1457555237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PLUMMER | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | MARTIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 MEDICAL CENTER DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826559 | ||||||||
| FaxNumber: | 5412826710 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 MEDICAL CENTER DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975044316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412826559 | ||||||||
| FaxNumber: | 5412826710 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2007 | ||||||||
| LastUpdateDate: | 05/13/2015 | ||||||||
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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 | 208600000X | MD156412 | OR | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | MD156412 | OR | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 500647780 | 05 | OR | MEDICAID | 165610 | 01 | OR | MEDICARE | OTHER | 4898026 | 01 | OR | BLUE CROSS | OTHER |