Basic Information
| Provider Information | |||||||||
| NPI: | 1538535059 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WVP MEDICAL GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | WVP INDEPENDENCE MONMOUTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2995 RYAN DR SE STE 200 | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973015157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033717701 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1430 MONMOUTH ST | ||||||||
| Address2: | |||||||||
| City: | INDEPENDENCE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973511127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5038381133 | ||||||||
| FaxNumber: | 5038385138 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2015 | ||||||||
| LastUpdateDate: | 04/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | ANDRETTA | ||||||||
| AuthorizedOfficialFirstName: | DEAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5033717701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MID VALLEY IPA, INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261Q00000X | Y | Ambulatory Health Care Facilities | Clinic/Center |
ID Information
| ID | Type | State | Issuer | Description | 288533 | 05 | OR | MEDICAID |